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Kang Y, Guo L, Li Q, Liu C, Jin W, Huang M, Liu Y, Tang C, Zhu J, Zhang L. Association of clopidogrel resistance and ABCD-GENE score with long-term clinical prognosis in patients with ischemic stroke or TIA. Rev Neurol (Paris) 2024; 180:682-688. [PMID: 38719768 DOI: 10.1016/j.neurol.2024.03.011] [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: 12/21/2023] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 08/25/2024]
Abstract
BACKGROUND Clopidogrel resistance (CR) is associated with adverse clinical outcomes in acute ischemic stroke or transient ischemic attack (TIA) patients. However, whether CR affects the long-term clinical prognosis remains to be clarified. The ABCD-GENE score is a novel risk model that identifies CR in cardiovascular disease patients; its diagnostic ability and application in ischemic stroke or TIA remain to be studied. This study aimed to investigate the diagnostic ability of the ABCD-GENE score for CR and analyze the relationship between CR and long-term clinical prognosis in patients with ischemic stroke or TIA. METHODS From January 2018 to January 2021, 251 ischemic stroke or TIA patients who were treated with clopidogrel for more than three months after onset and maintained the medication until the follow-up time were enrolled, and platelet reactivity was detected by thromboelastography. CYP2C19 gene analysis was performed. Adverse clinical outcomes were recorded from 3months after onset. The median follow-up time was 878days. RESULTS The prevalence of CR was 33.9%. The proportion of CYP2C19 loss-of-function carriers was 62.2%. The ABCD-GENE score≥10 was independently associated with CR (OR=1.82, 95% CI: 1.02-3.24, P=0.041), and the C-statistic value of the score (as a binary and integer variable) on CR was 0.58 and 0.63, respectively. The risk of long-term adverse clinical outcomes was not significantly different between CR and clopidogrel sensitive groups (12.94% vs. 11.44%, HR=1.22, 95% CI: 0.57-2.62, P=0.603). A similar result was observed between ABCD-GENE score≥10 and ABCD-GENE score<10 groups (10.38% vs. 12.64%, HR=1.19, 95% CI: 0.55-2.60, P=0.666). CONCLUSIONS In ischemic stroke or TIA patients, the ABCD-GENE score could identify the risk of CR. CR was not associated with long-term adverse clinical outcomes.
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Affiliation(s)
- Y Kang
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - L Guo
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - Q Li
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - C Liu
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - W Jin
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - M Huang
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - Y Liu
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - C Tang
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - J Zhu
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China
| | - L Zhang
- Department of Neurology and Centre for Clinical Neuroscience, Daping Hospital, Army Medical Centre of PLA, Army Medical University, Chongqing, China.
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Sharma R, Aggarwal G, Kumar A, Thakur AK, Pandit M, Sharma V, Singh M, Majeed J, Ajmera P. Effect of loss-of-function CYP2C19 variants on clinical outcomes in coronary artery disease patients treated with clopidogrel: A systematic meta-analysis approach. Int J Cardiol 2024; 414:132418. [PMID: 39121919 DOI: 10.1016/j.ijcard.2024.132418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024]
Abstract
For many years, clopidogrel has been a commonly utilised antiplatelet drug in the management of coronary artery disease (CAD). It's thought that the CYP2C19 loss of function (LoF) polymorphism causes clopidogrel's poor metabolism, which eventually leads to resistance. Previous research produced extremely divergent and inconsistent results, making it impossible to draw definitive conclusions. Therefore, current, investigation was carried out to obtain definitive evidence from an updated meta-analysis on the connection between CYP2C19 LoF polymorphism and coronary artery event in patients treated with clopidogrel. 52,542 individuals with coronary artery disease who were receiving clopidogrel treatment were included in 87 carefully chosen trials from reliable databases that we used for our meta-analysis. According to our data, those who carry one or more CYP2C19 LoF alleles worldwide are much more likely to experience composite events and coronary artery events than people who do not carry these alleles, especially in Asian populations. Our meta-analysis observed that the global population, particularly Asians receiving clopidogrel treatment, is at risk of recurrent coronary artery events and composite events if they carry the CYP2C19 LoF alleles. Additional research is essential on alternative antiplatelet therapies for individuals who exhibit poor or intermediate metabolic activity. OBJECTIVES: 1.To systematically analyze the current evidence regarding the association of CYP2C19 variants with coronary artery disease (CAD). 2.To conduct a meta-analysis to investigate the association between loss of function (LoF) CYP2C19 modifications and CAD.
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Affiliation(s)
- Ruchika Sharma
- Centre for Precision Medicine and Pharmacy, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India
| | - Geeta Aggarwal
- Department of Pharmaceutics, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India
| | - Anoop Kumar
- Department of Pharmacology, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India
| | - Ajit K Thakur
- Department of Pharmacology, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India
| | | | | | | | - Jaseela Majeed
- School of Allied Health Sciences and Management, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India.
| | - Puneeta Ajmera
- School of Allied Health Sciences and Management, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India.
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Pereira NL, Cresci S, Angiolillo DJ, Batchelor W, Capers Q, Cavallari LH, Leifer D, Luzum JA, Roden DM, Stellos K, Turrise SL, Tuteja S. CYP2C19 Genetic Testing for Oral P2Y12 Inhibitor Therapy: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e129-e150. [PMID: 38899464 PMCID: PMC11300169 DOI: 10.1161/cir.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record.
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Elserwey A, Jabbour RJ, Curzen N. Does one size really fit all? The case for personalized antiplatelet therapy in interventional cardiology. Future Cardiol 2024:1-17. [PMID: 39093436 DOI: 10.1080/14796678.2024.2384217] [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: 03/06/2024] [Accepted: 07/22/2024] [Indexed: 08/04/2024] Open
Abstract
Cardiovascular disease is the leading cause of death worldwide. Dual antiplatelet therapy (DAPT), with aspirin plus a P2Y12 inhibitor, is currently recommended as a default for patients after acute coronary syndrome (ACS) and following percutaneous coronary intervention (PCI). However, controversies arise over the role of aspirin, the optimal duration of DAPT after drug-eluting stent (DES) implantation, the choice of P2Y12 inhibitor and the variability in individual responses to antiplatelet agents. Recent data indicate that monotherapy with a P2Y12 inhibitor may have adequate anti-ischemic effects with lower bleeding risk. Additionally, discrepancies in DAPT duration recommendations and the optimal P2Y12 inhibitor, provides more uncertainty. We ask the question "does one size really fits all?" or should a more personalized strategy should be implemented.
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Affiliation(s)
- Ahmed Elserwey
- Faculty of Medicine, University of Southampton
- University Hospital Southampton NHS FT
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton
- University Hospital Southampton NHS FT
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Cavallari LH, Lee CR, Franchi F, Keeley EC, Rossi JS, Thomas CD, Gong Y, McDonough CW, Starostik P, Al Saeed MJ, Been L, Kulick N, Malave J, Mulrenin IR, Nguyen AB, Terrell JN, Tillotson G, Beitelshees AL, Winterstein AG, Stouffer GA, Angiolillo DJ. Precision Antiplatelet Therapy after Percutaneous Coronary Intervention (Precision PCI) Registry - Informing optimal antiplatelet strategies. Clin Transl Sci 2024; 17:e70004. [PMID: 39150361 PMCID: PMC11328342 DOI: 10.1111/cts.70004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) is indicated after percutaneous coronary intervention (PCI) to reduce the risk of atherothrombotic events. Approximately 30% of the US population has a CYP2C19 no-function allele that reduces the effectiveness of clopidogrel, but not prasugrel or ticagrelor, after PCI. We have shown improved outcomes with the integration of CYP2C19 genotyping into clinical care to guide the selection of prasugrel or ticagrelor in CYP2C19 no-function allele carriers. However, the influence of patient-specific demographic, clinical, and other genetic factors on outcomes with genotype-guided DAPT has not been defined. In addition, the impact of genotype-guided de-escalation from prasugrel or ticagrelor to clopidogrel in patients without a CYP2C19 no-function allele has not been investigated in a diverse, real-world clinical setting. The Precision Antiplatelet Therapy after Percutaneous Coronary Intervention (Precision PCI) Registry is a multicenter US registry of patients who underwent PCI and clinical CYP2C19 testing. The registry is enrolling a diverse population, assessing atherothrombotic and bleeding events over 12 months, collecting DNA samples, and conducting platelet function testing in a subset of patients. The registry aims to define the influence of African ancestry and other patient-specific factors on clinical outcomes with CYP2C19-guided DAPT, evaluate the safety and effectiveness of CYP2C19-guided DAPT de-escalation following PCI in a real-world setting, and identify additional genetic influences of clopidogrel response after PCI, with the ultimate goal of establishing optimal strategies for individualized antiplatelet therapy that improves outcomes in a diverse, real-world population.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine‐JacksonvilleUniversity of FloridaJacksonvilleFloridaUSA
| | - Ellen C. Keeley
- Division of Cardiovascular Medicine, College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Joseph S. Rossi
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine; College of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Maryam J. Al Saeed
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Latonya Been
- Division of Cardiology, Department of Medicine, College of Medicine‐JacksonvilleUniversity of FloridaJacksonvilleFloridaUSA
| | - Natasha Kulick
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Jean Malave
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Ian R. Mulrenin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Joshua N. Terrell
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Grace Tillotson
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and Safety, College of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine‐JacksonvilleUniversity of FloridaJacksonvilleFloridaUSA
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6
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AlSaeed MJ, Thomas CD, Franchi F, Keeley EC, Duarte JD, Gong Y, Rossi JS, Beitelshees AL, Stouffer GA, Lee CR, Angiolillo DJ, Cavallari LH. Evaluating the Effect of Estimating Renal Function With the CKD-EPI 2021 Equation on the ABCD-GENE Score for Clopidogrel Response Prediction. Clin Pharmacol Ther 2024. [PMID: 39031256 DOI: 10.1002/cpt.3385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/04/2024] [Indexed: 07/22/2024]
Abstract
The ABCD-GENE score was developed to predict poor response to clopidogrel and includes Age, Body mass index, Chronic kidney disease (CKD; estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2), Diabetes, and CYP2C19 GENE variants; a score ≥ 10 is predictive of reduced clopidogrel effectiveness after percutaneous coronary intervention (PCI). Estimation of GFR without a race variable via the CKD-EPI Scr 2021 equation is now recommended. We examined the impact of using the CKD-EPI Scr 2021 vs. 2009 equation on the ABCD-GENE score for post-PCI patients. A total of 4335 adult patients (n = 925 Black) who underwent PCI and CYP2C19 genotyping were included, with GFR estimated for each patient via the CKD-EPI Scr 2021 and CKD-EPI 2009 equations. The ABCD-GENE score, calculated based on each GFR estimation, was compared. With the CKD-EPI Scr 2021 vs. 2009 equation, median (IQR) eGFR was lower (74 [55-94] vs. 81 [60-103] mL/min/1.73 m2, P < 0.001), and CKD prevalence was higher (31% vs. 25%, P < 0.001) among Black patients, whereas eGFR was higher (85 [65-99] vs. 80 [61-94] mL/min/1.73m2, P < 0.001), and CKD prevalence was lower (20% vs. 24%, P < 0.001) in non-Black patients. This led to 12 (1%) Black patients being reclassified from low to high risk of poor clopidogrel response and 30 (1%) non-Black patients being recategorized from high to low risk (P < 0.001 for both comparisons). Removal of the race variable from GFR estimation significantly impacted the prediction of clopidogrel effectiveness via the ABCD-GENE score.
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Affiliation(s)
- Maryam Jamal AlSaeed
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al Hofuf, Saudi Arabia
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Joseph S Rossi
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amber L Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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7
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Ortega-Paz L, Franchi F, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Mahowald MK, Langaee T, Jakubowski JA, Cavallari LH, Angiolillo DJ. Clopidogrel-Mediated P2Y 12 Inhibition According to Renal Function in Patients With Diabetes Mellitus and CAD. JACC Basic Transl Sci 2024; 9:865-876. [PMID: 39170956 PMCID: PMC11334417 DOI: 10.1016/j.jacbts.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 08/23/2024]
Abstract
This prospective ex vivo and in vitro pharmacodynamic (PD)/pharmacokinetic investigation was conducted in patients with diabetes mellitus with (n = 31) and without chronic kidney disease (n = 30). PD assessments included platelet reactivity index, maximum platelet aggregation, and P2Y12 reaction units. Ex vivo pharmacokinetic assessments included plasma levels of clopidogrel and its active metabolite. In vitro PD assessments were conducted on baseline samples incubated with escalating concentrations of clopidogrel and its active metabolite. Among patients with diabetes mellitus treated with clopidogrel, impaired renal function was associated with increased maximum platelet aggregation. This finding could be attributed partially to upregulation of the P2Y12 activity without differences in drug absorption or metabolism. (Impact of Chronic Kidney Disease on Clopidogrel Effects in Diabetes Mellitus; NCT03774394).
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Andres M. Pineda
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Martin M. Zenni
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Madeline K. Mahowald
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy University of Florida, Gainesville, Florida, USA
| | | | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy University of Florida, Gainesville, Florida, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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8
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Scorpiglione L, Pizzicannella J, Bacigalupi E, Cicchitti V, Pelliccia F, Foglietta M, Gallina S, Zimarino M. Therapeutic strategies aiming at the reduction of the antiplatelet intensity should not overlook the ischemic risk in patients with coronary syndromes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00546-3. [PMID: 38987047 DOI: 10.1016/j.carrev.2024.06.015] [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: 01/25/2024] [Revised: 05/22/2024] [Accepted: 06/17/2024] [Indexed: 07/12/2024]
Abstract
De-escalation of dual antiplatelet therapy (DAPT) is gaining traction as a strategy to reduce bleeding risks while ensuring ischemic outcomes. Undiscriminating de-escalation, notably in patients with high ischemic risk, might expose them to major adverse cardiac events. Platelet function and genetic tests are emerging tools to guide de-escalation, but both present specific drawbacks. Recent meta-analyses have aimed to consolidate the findings of individual trials to provide clearer insights. Yet, limitations remain for patients with concomitant high bleeding and ischemic risks. These high-risk patients are frequently underrepresented in clinical trials, and, therefore, currently available guidelines lack evidence-based recommendations for this subset. While DAPT de-escalation strategies hold promise, the choice of approach, whether clinically or assay-guided, remains complex and should be individualized.
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Affiliation(s)
- Luca Scorpiglione
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Jacopo Pizzicannella
- Department of Engineering and Geology, "G. d'Annunzio" University, Chieti-Pescara, Italy; Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy.
| | - Elena Bacigalupi
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Vincenzo Cicchitti
- Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | | | - Melissa Foglietta
- Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy; Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
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9
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Tunehag KR, Thomas CD, Franchi F, Rossi JS, Keeley EC, Anderson RD, Beitelshees AL, Duarte JD, Gong Y, Kerensky RA, McDonough CW, Nguyen AB, Ortega‐Paz L, Venkatesh S, Wang Y, Johnson JA, Winterstein AG, Stouffer GA, Angiolillo DJ, Cavallari LH, Lee CR. CYP2C19 Genotype Is Associated With Adverse Cardiovascular Outcomes in Black Patients Treated With Clopidogrel Undergoing Percutaneous Coronary Intervention. J Am Heart Assoc 2024; 13:e033791. [PMID: 38874073 PMCID: PMC11255757 DOI: 10.1161/jaha.123.033791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/13/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Cytochrome P450 2C19 (CYP2C19) intermediate and poor metabolizer patients exhibit diminished clopidogrel clinical effectiveness after percutaneous coronary intervention (PCI). However, outcome studies to date have lacked racial diversity. Thus, the impact of CYP2C19 genotype on cardiovascular outcomes in patients treated with clopidogrel who identify as Black or African American remains unclear. METHODS AND RESULTS Adults among 5 institutions who self-identified as Black or African American, underwent PCI and clinical CYP2C19 genotyping, and were treated with clopidogrel were included. Data were abstracted from health records. Major atherothrombotic (composite of death, myocardial infarction, ischemic stroke, stent thrombosis, or revascularization for unstable angina) and bleeding event rates within 1 year after PCI were compared across CYP2C19 metabolizer groups using multivariable Cox regression adjusted for potential confounders and baseline variables meeting a threshold of P<0.10. The population included 567 Black patients treated with clopidogrel (median age, 62 years; 46% women; 70% with an acute coronary syndrome indication for PCI). Major atherothrombotic events rates were significantly higher among clopidogrel-treated intermediate and poor metabolizers (24 of 125 [19.2%]) versus patients treated with clopidogrel without a no function allele (43 of 442 [9.7%]; 35.1 versus 15.9 events per 100 person-years; adjusted hazard ratio, 2.00 [95% CI, 1.20-3.33], P=0.008). Bleeding event rates were low overall (23 of 567 [4.1%]) and did not differ among the metabolizer groups. CONCLUSIONS Black patients with CYP2C19 intermediate and poor metabolizer phenotypes who are treated with clopidogrel exhibit increased risk of adverse cardiovascular outcomes after PCI in a real-world clinical setting. Bleeding outcomes should be interpreted cautiously. Prospective studies are needed to determine whether genotype-guided use of prasugrel or ticagrelor in intermediate and poor metabolizers improves outcomes in Black patients undergoing PCI.
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Affiliation(s)
- Kayla R. Tunehag
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Cameron D. Thomas
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Francesco Franchi
- Division of Cardiology, Department of MedicineCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFLUSA
| | - Joseph S. Rossi
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Ellen C. Keeley
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - R. David Anderson
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - Amber L. Beitelshees
- University of Maryland School of MedicineDepartment of Medicine and Program for Personalized and Genomic MedicineBaltimoreMDUSA
| | - Julio D. Duarte
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Yan Gong
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Richard A. Kerensky
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Luis Ortega‐Paz
- Division of Cardiology, Department of MedicineCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFLUSA
| | - Sanjay Venkatesh
- Division of Cardiology, Duke Department of MedicineDuke University School of MedicineDurhamNCUSA
| | - Yehua Wang
- Department of Pharmaceutical Outcomes & Policy, Department of Epidemiology, and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFLUSA
| | - Julie A. Johnson
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
- Division of Cardiovascular MedicineCollege of Medicine, University of FloridaGainesvilleFLUSA
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy, Department of Epidemiology, and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFLUSA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of MedicineCollege of Medicine‐Jacksonville, University of FloridaJacksonvilleFLUSA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy & Translational Research and Center for Pharmacogenomics and Precision MedicineCollege of Pharmacy, University of FloridaGainesvilleFLUSA
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Division of Cardiology and McAllister Heart Institute, School of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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10
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Pradhan A, Bhandari M, Vishwakarma P, Sethi R. Clopidogrel resistance and its relevance: Current concepts. J Family Med Prim Care 2024; 13:2187-2199. [PMID: 39027844 PMCID: PMC11254075 DOI: 10.4103/jfmpc.jfmpc_1473_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 07/20/2024] Open
Abstract
Clopidogrel is the most widely used P2Y12 receptor inhibitor (P2Y12i) as a part of dual antiplatelet therapy along with aspirin. Clopidogrel is a pro-drug and is metabolized to its active metabolite by the hepatic enzyme cytochrome P4502C19 (CYP2C19). This active metabolite is responsible for the antiplatelet action of clopidogrel. Recent studies have demonstrated that single nucleotide polymorphisms in the CYP2C19 gene, including CYP2C19*2,*3,*4, and *5 alleles, result in reduced production of the active metabolite of clopidogrel, and hence reduced inhibition of platelet aggregation. This in turn enhances the incidence of stent thrombosis and recurrent cardiovascular (CV) events. We report a case of coronary stent thrombosis due to clopidogrel resistance proven by CYP2C19 genotyping. We then review the literature on clopidogrel resistance and its impact on CV outcomes. Subsequently, we discuss the methods of diagnosis of resistance, evidence from clinical trials for tailoring clopidogrel therapy, the role of potent P2Y12 inhibitors, the current guidelines, and future directions.
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Affiliation(s)
- Akshyaya Pradhan
- Department of Cardiology, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Monika Bhandari
- Department of Cardiology, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Pravesh Vishwakarma
- Department of Cardiology, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Rishi Sethi
- Department of Cardiology, King George’s Medical University, Lucknow, Uttar Pradesh, India
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11
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Landolina D, Ammirabile N, Capodanno D. Strategies for Tailored Antiplatelet Therapy after Percutaneous Coronary Intervention: Unraveling Complexities, Embracing Nuances. Thromb Haemost 2024; 124:497-499. [PMID: 37722600 DOI: 10.1055/a-2177-4220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Affiliation(s)
- Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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12
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Chang WT, Huang PS, Su LW, Liao CT, Siong Toh H, Chen YC, Chung‑Han H, Chen ZC, Hsu PC, Hong CS. Utility of the ACD-GENE-CLI Score in Asian Patients with Critical Limb Ischemia Undergoing Endovascular Interventions. J Atheroscler Thromb 2024; 31:572-586. [PMID: 38092392 PMCID: PMC11079481 DOI: 10.5551/jat.64326] [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: 04/17/2023] [Accepted: 10/19/2023] [Indexed: 05/03/2024] Open
Abstract
AIMS Critical limb ischemia (CLI) is an emerging public health threat and lacks a reliable score for predicting the outcomes. The Age, Body Mass Index, Chronic Kidney Disease, Diabetes, and Genotyping (ABCD-GENE) risk score helps identify patients with coronary artery disease who have cytochrome P450 2C19 (CYP2C19) polymorphism-related drug resistance and are at risk for cardiovascular adverse events. However, its application to CLI remains unknown. In this study, we aim to validate a modified ACD-GENE-CLI score to improve the prediction of major adverse limb events (MALEs) in patients with CLI receiving clopidogrel. METHODS Patients with CLI receiving clopidogrel post-endovascular intervention were enrolled prospectively in two medical centers. Amputation and revascularization as MALEs were regarded as the outcomes. RESULTS A total of 473 patients were recruited, with a mean follow-up duration of 25 months. Except for obesity, old age, diabetes, chronic kidney disease (CKD), and CYP2C19 polymorphisms were significantly associated with MALEs. Using bootstrap regression analysis, we established a modified risk score (ACD-GENE-CLI) that included old age (≥ 65 years), diabetes, CKD, and CYP2C19 polymorphisms. At a cutoff value of 8, the ACD-GENE-CLI score was superior to the CYP2C19 deficiency only, and the conventional ABCD-GENE score in predicting MALEs (area under the curve: 0.69 vs. 0.59 vs. 0.67, p=0.01). The diagnostic ability of the ACD-GENE-CLI score was consistent in the external validation. Also, Kaplan-Meier curves showed that in CYP2C19 deficiency, the ABCD-GENE and ACD-GENE-CLI scores could all differentiate patients with CLI who are free from MALEs. CONCLUSIONS The modified ACD-GENE-CLI score could differentiate patients with CLI receiving clopidogrel who are at risk of MALEs. Further studies are required to generalize the utility of the score.
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Affiliation(s)
- Wei-Ting Chang
- School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-sen University, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Sen Huang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Li-Wei Su
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Te Liao
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Han Siong Toh
- Department of Intensive Care Medicine, Chi Mei Medical Centre, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Yi-Chen Chen
- Department of Medical Research, Chi-Mei Medical Center, Tainan
| | - Ho Chung‑Han
- Department of Medical Research, Chi-Mei Medical Center, Tainan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Internal Medicine, Faculty of Medicine, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chon-Seng Hong
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
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13
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Thomas CD, Franchi F, Rossi JS, Keeley EC, Anderson RD, Beitelshees AL, Duarte JD, Ortega-Paz L, Gong Y, Kerensky RA, Kulick N, McDonough CW, Nguyen AB, Wang Y, Winget M, Yang WE, Johnson JA, Winterstein AG, Stouffer GA, Angiolillo DJ, Lee CR, Cavallari LH. Effectiveness of Clopidogrel vs Alternative P2Y 12 Inhibitors Based on the ABCD-GENE Score. J Am Coll Cardiol 2024; 83:1370-1381. [PMID: 38599713 PMCID: PMC11074948 DOI: 10.1016/j.jacc.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND An ABCD-GENE (age, body mass index, chronic kidney disease, diabetes, and CYP2C19 genetic variants) score ≥10 predicts reduced clopidogrel effectiveness, but its association with response to alternative therapy remains unclear. OBJECTIVES The aim of this study was to evaluate the association between ABCD-GENE score and the effectiveness of clopidogrel vs alternative P2Y12 inhibitor (prasugrel or ticagrelor) therapy after percutaneous coronary intervention (PCI). METHODS A total of 4,335 patients who underwent PCI, CYP2C19 genotyping, and P2Y12 inhibitor treatment were included. The primary outcome was major atherothrombotic events (MAE) within 1 year after PCI. Cox regression was performed to assess event risk in clopidogrel-treated (reference) vs alternatively treated patients, with stabilized inverse probability weights derived from exposure propensity scores after stratifying by ABCD-GENE score and further by CYP2C19 loss-of-function (LOF) genotype. RESULTS Among patients with scores <10 (n = 3,200), MAE was not different with alternative therapy vs clopidogrel (weighted HR: 0.89; 95% CI: 0.65-1.22; P = 0.475). The risk for MAE also did not significantly differ by treatment among patients with scores ≥10 (n = 1,135; weighted HR: 0.75; 95% CI: 0.51-1.11; P = 0.155). Among CYP2C19 LOF allele carriers, MAE risk appeared lower with alternative therapy in both the group with scores <10 (weighted HR: 0.50; 95% CI: 0.25-1.01; P = 0.052) and the group with scores ≥10 (weighted HR: 0.48; 95% CI: 0.29-0.80; P = 0.004), while there was no difference in the group with scores <10 and no LOF alleles (weighted HR: 1.03; 95% CI: 0.70-1.51; P = 0.885). CONCLUSIONS These data support the use of alternative therapy over clopidogrel in CYP2C19 LOF allele carriers after PCI, regardless of ABCD-GENE score, while clopidogrel is as effective as alternative therapy in non-LOF patients with scores <10.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Joseph S Rossi
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - R David Anderson
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amber L Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Richard A Kerensky
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Natasha Kulick
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Anh B Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yehua Wang
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Marshall Winget
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William E Yang
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA; Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida, USA
| | - Craig R Lee
- Division of Cardiology and McAllister Heart Institute, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA.
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14
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Ding LP, Li P, Yang LR, Pan MM, Zhou M, Zhang C, Yan YD, Lin HW, Li XY, Gu ZC. A novel machine learning model to predict high on-treatment platelet reactivity on clopidogrel in Asian patients after percutaneous coronary intervention. Int J Clin Pharm 2024; 46:90-100. [PMID: 37817027 DOI: 10.1007/s11096-023-01638-1] [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: 06/17/2023] [Accepted: 08/16/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Various genetic and nongenetic variables influence the high on-treatment platelet reactivity (HTPR) in patients taking clopidogrel. AIM This study aimed to develop a novel machine learning (ML) model to predict HTPR in Chinese patients after percutaneous coronary intervention (PCI). METHOD This cohort study collected information on 507 patients taking clopidogrel. Data were randomly divided into a training set (90%) and a testing set (10%). Nine candidate Machine learning (ML) models and multiple logistic regression (LR) analysis were developed on the training set. Their performance was assessed according to the area under the receiver operating characteristic curve, precision, recall, F1 score, and accuracy on the test set. Model interpretations were generated using importance scores by transforming model variables into scaled features and representing in radar plots. Finally, we established a prediction platform for the prediction of HTPR. RESULTS A total of 461 patients (HTPR rate: 19.52%) were enrolled in building the prediction model for HTPR. The XGBoost model had an optimized performance, with an AUC of 0.82, a precision of 0.80, a recall of 0.44, an F1 score of 0.57, and an accuracy of 0.87, which was superior to those of LR. Furthermore, the XGBoost method identified 7 main predictive variables. To facilitate the application of the model, we established an XGBoost prediction platform consisting of 7 variables and all variables for the HTPR prediction. CONCLUSION A ML-based approach, such as XGBoost, showed optimum performance and might help predict HTPR on clopidogrel after PCI and guide clinical decision-making. Further validated studies will strengthen this finding.
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Affiliation(s)
- Lan-Ping Ding
- Department of Pharmacy, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210009, China
| | - Ping Li
- Department of Pharmacy, Women and Children's Hospital, Qingdao University, Qingdao, 266034, China
| | - Li-Rong Yang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Mang-Mang Pan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Min Zhou
- Nanjing Ericsson Panda Communication Co. Ltd.,, Nanjing, 211100, China
| | - Chi Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Yi-Dan Yan
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Hou-Wen Lin
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Xiao-Ye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China.
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15
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Voicu V, Diehm N, Moarof I, Parejo S, Badiqué F, Burden A, Niedrig D, Béchir M, Russmann S. Antiplatelet therapy guided by CYP2C19 point-of-care pharmacogenetics plus multidimensional treatment decisions. Pharmacogenomics 2024; 25:5-19. [PMID: 38230622 DOI: 10.2217/pgs-2023-0200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
Aim: Implementation of CYP2C19 point-of-care (POC) pharmacogenetic (PGx) testing with personalized treatment recommendations. Methods: POC CYP2C19 genotyping plus expert evaluation of risk factors for ischemic and bleeding events. Results: 167 patients underwent PGx testing, 54 (32.3%) were CYP2C19 loss of function carriers, and POC versus standard PGx analysis results for *2 and *3 variants matched in 100%. Antiplatelet therapy was adjusted in 44 patients (26.3%), but always required consideration of patient-specific factors. Conclusion: CYP2C19 POC-PGx is reliable and offers clinically relevant advantages for immediate evidence-based adaptations of antiplatelet therapy, whereas in less acute cases conventional PGx testing can also have advantages. Antiplatelet therapy has become more complex, and implementation of PGx-based personalized antiplatelet therapy requires complementary expert knowledge.
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Affiliation(s)
- Victor Voicu
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
| | - Nicolas Diehm
- Center for Vascular Medicine, 5000, Aarau, Switzerland
| | - Igal Moarof
- Cardiology Center Mittelland, 5001, Aarau, Switzerland
| | - Sarah Parejo
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Florent Badiqué
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Andrea Burden
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
| | - David Niedrig
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Hospital Pharmacy, Clinic Hirslanden Zurich, 8032, Zurich, Switzerland
| | - Markus Béchir
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
| | - Stefan Russmann
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
- University of Nicosia Medical School, 2408, Nicosia-Egkomi, Cyprus
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16
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Goto H, Saito Y, Matsumoto T, Sato T, Yamashita D, Suzuki S, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. Differential Impact of Clinical Factors for Predicting High Platelet Reactivity on Clinical Outcomes in Acute Myocardial Infarction Patients Treated With Clopidogrel and Prasugrel. J Atheroscler Thromb 2023; 30:1791-1802. [PMID: 37316266 DOI: 10.5551/jat.64217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
AIMS Several scoring systems, including the ABCD-GENE and HHD-GENE scores incorporating clinical and genetic factors, have been developed to identify patients likely to have high platelet reactivity on P2Y12 inhibitors, leading to increased risks of ischemic events. However, genetic testing is not widely available in daily practice. We aimed to evaluate the differential impact of clinical factors in the scores on ischemic outcomes in patients treated with clopidogrel and prasugrel. METHODS This bi-center registry included 789 patients with acute myocardial infarction (MI) undergoing percutaneous coronary intervention and treated with either clopidogrel or prasugrel at discharge. The relations of the number of clinical factors included in the ABCD-GENE (age ≥ 75 years, body mass index >30 kg/m2, chronic kidney disease, and diabetes) and HHD-GENE (hypertension, hemodialysis, and diabetes) scores to the primary endpoint of major cardiovascular events after discharge, a composite of death, recurrent MI, and ischemic stroke, were evaluated. RESULTS The number of clinical factors in the ABCD-GENE score was not predictive of ischemic outcomes after discharge in patients treated with clopidogrel and/or prasugrel, while the increase in the number of clinical factors of the HHD-GENE score was associated with an increased risk of the primary endpoint in a stepwise manner in patients on a P2Y12 inhibitor. CONCLUSIONS Clinical factors listed in the HHD-GENE score may help stratify ischemic risks in patients with acute MI treated with clopidogrel and prasugrel, whereas risk stratification without genetic testing in patients treated with clopidogrel may be challenging.
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Affiliation(s)
- Hiroki Goto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | | | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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Nakahashi T, Sakata K, Tada H. Comparative Effects of Genetic and Nongenetic Factors in Antithrombotic Strategy. J Atheroscler Thromb 2023; 30:1763-1765. [PMID: 37730374 DOI: 10.5551/jat.ed242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Affiliation(s)
- Takuya Nakahashi
- Division of Cardiology, Department of Internal Medicine, Takaoka City Hospital
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
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18
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Gao H, Yang N, Yang L, Wang H, Zhang G, Ma X, Deng N. Advances and Perspectives in methods for identifying high platelet reactivity. Heliyon 2023; 9:e22214. [PMID: 38107326 PMCID: PMC10724541 DOI: 10.1016/j.heliyon.2023.e22214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy is the foundational treatment for the prevention and treatment of coronary and cerebrovascular ischemic events in patients with coronary heart disease, ischemic stroke, and transient ischemic attack (TIA). However, with more and more studies reporting an increased risk of thrombosis in some patients due to poor response to therapeutic agents, the selection of appropriate P2Y12 inhibitors has become a major challenge that needs to be addressed urgently. Currently, commonly used oral P2Y12 inhibitors include clopidogrel, ticagrelor, and prasugrel. Assessing patients' risk factors before the development of treatment regimens by effectively predicting the risk of high platelet reactivity with specific P2Y12 inhibitors in advance to avert the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) is the key point to the problem. Up to now, methods available for predicting platelet reactivity include genetic testing, platelet function testing, and risk scores. This review provides a summarization of the existent available identification methods and analyzes the advantages and drawbacks of different methods in specific clinical settings, intending to guide the rational clinical application of P2Y12 receptor inhibitors.
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Affiliation(s)
- Hua Gao
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Nan Yang
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Libo Yang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Hui Wang
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Guoshan Zhang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xueping Ma
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Ning Deng
- Office of Drug Clinical Trial Organization, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
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19
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Cargnin S, Ferrari F, Terrazzino S. Impact of CYP2C19 Genotype on Efficacy and Safety of Clopidogrel-based Antiplatelet Therapy in Stroke or Transient Ischemic Attack Patients: An Updated Systematic Review and Meta-analysis of Non-East Asian Studies. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07534-0. [PMID: 38038819 DOI: 10.1007/s10557-023-07534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE Inconclusive and limited results have been reported on the clinical utility of CYP2C19 genotyping in stroke/TIA patients of non-East Asian ancestries. We herein performed an updated systematic review and meta-analysis to quantitatively estimate the association of CYP2C19 loss-of function (LOF) status with efficacy and safety of clopidogrel-based antiplatelet therapy in non-East Asian patients affected by stroke or TIA. METHODS A comprehensive search was performed up to July 2023 using PubMed, Web of Knowledge, and Cochrane Library databases. The clinical outcomes investigated were stroke, composite vascular events and bleeding. Pooled estimates were calculated as risk ratios (RR) with 95% CI using the Mantel- Haenszel random-effects model. The quality of evidence was assessed using the GRADEpro tool. RESULTS A total number of 1673 stroke/TIA patients from 8 non-East Asian studies, published between 2014 and 2022, were included in the systematic review. Clopidogrel-treated carriers of CYP2C19 LOF alleles were found at increased risk of stroke compared to non-carriers (RR: 1.68, 95%CI: 1.04-2.71, P = 0.03). However, no significant association was observed with the risk of composite vascular events (RR: 1.15, 95%CI: 0.58-2.28, P = 0.69) or bleeding (RR: 0.84, 95%CI: 0.38-1.86, P = 0.67). Similarly, European ancestry patients carrying CYP2C19 LOF alleles displayed a higher risk of stroke (RR: 2.69 (1.11-6.51, P = 0.03), but not of composite vascular events or bleeding. CONCLUSION The present updated meta-analysis provides moderate quality evidence of association between CYP2C19 LOF alleles and an increased risk of stroke in non-East Asian patients with stroke/TIA after receiving clopidogrel therapy. Further large pharmacogenetic studies are still warranted to corroborate these findings.
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Affiliation(s)
- Sarah Cargnin
- Department of Health Sciences, Università del Piemonte Orientale (UPO), Novara, Italy
| | - Federica Ferrari
- Dept of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Department of Emergency Neurology and Stroke Unit, IRCCS Mondino Foundation, Pavia, 27100, Italy
| | - Salvatore Terrazzino
- Department of Pharmaceutical Sciences, University of Piemonte Orientale A. Avogadro. Largo, Donegani 2, Novara, 28100, Italy.
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20
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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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21
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Sandner S, Redfors B, Gaudino M. Antiplatelet therapy around CABG: the latest evidence. Curr Opin Cardiol 2023; 38:484-489. [PMID: 37751394 PMCID: PMC10552805 DOI: 10.1097/hco.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The optimal antiplatelet strategy in patients after coronary artery bypass graft (CABG) surgery is unclear. We review the evidence on the efficacy and safety of DAPT after CABG and discuss potential novel antiplatelet strategies that reduce the risk of bleeding without loss of efficacy. RECENT FINDINGS Adding the potent P2Y12 inhibitor ticagrelor to aspirin for 1 year after CABG is associated with a reduction in the risk of vein graft failure, at the expense of an increased risk of clinically important bleeding. Ticagrelor monotherapy is not associated with better efficacy than aspirin alone, but is not associated with increased bleeding risk. SUMMARY Dual antiplatelet therapy (DAPT) is recommended after acute coronary syndrome events, but aspirin as single antiplatelet therapy remains the cornerstone of antithrombotic therapy in stable ischemic heart disease because of a lack of solid evidence on the benefit of DAPT on clinical outcomes. Shorter duration DAPT, based on the pathophysiology of vein graft failure, may be a promising strategy that requires testing in adequately powered randomized trials.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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22
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Tan CK, Wu DBC, Joseph Tan SY, Imran SS, Wee XT, Tan SYD. Validating the Prognostic Utility of the ABCD-GENE Score in Asian Patients with Acute Coronary Syndrome Patients on Clopidogrel. Eur Cardiol 2023; 18:e60. [PMID: 38023338 PMCID: PMC10658354 DOI: 10.15420/ecr.2023.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background The ABCD-GENE score, which links cytochrome P450 2C19 (CYP2C19) phenotype and high platelet reactivity (HPR) to the risk of major adverse cardiovascular events (MACE) in clopidogrel users, has been validated in white and Japanese populations. The prognostic implications of the score in other Asian cohorts, however, have been largely unchartered. The aim of this study was to validate the prognostic utility of the ABCD-GENE score in a heterogeneous Asian acute coronary syndrome (ACS) cohort. Methods and Results In this single-centre, retrospective cohort evaluation of 423 ACS patients, the objectives were to characterise the best cut-off score for MACE prognostication by comparing the adjusted 1-year risk of MACE between groups above and below the candidate cut-off scores using Cox regression; and for on-clopidogrel HPR prediction using receiver operating characteristic (ROC) analysis and Youden's index. In the adjusted Cox model, an ABCD-GENE score cut-off at 10 points significantly predicts the 1-year risk of MACE (adjusted HR 3.771; 95% CI [1.041-13.661]). Female sex, baseline LDL, history of ACS and angiotensin receptor blocker use were additional independent predictors of MACE. On ROC analysis the ideal cut-off for HPR prediction was 7 points. However, that did not independently predict the 1-year risk of MACE (adjusted HR 1.595; 95% CI [0.425-5.989]). Conclusion The original ABCD-GENE score 10-point cut-off moderately predicts MACE in a heterogeneous, Asian ACS population at 1 year. Additional predictors of MACE were also identified in the present cohort, and these findings should be prospectively validated in larger ACS cohorts.
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Affiliation(s)
| | - David Bin-Chia Wu
- Saw Swee Hock School of Public Health, National University of SingaporeSingapore
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23
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Chanfreau-Coffinier C, Friede KA, Plomondon ME, Lee KM, Lu Z, Lynch JA, DuVall SL, Vassy JL, Waldo SW, Cleator JH, Maddox TM, Rader DJ, Assimes TL, Damrauer SM, Tsao PS, Chang KM, Voora D, Giri J, Tuteja S. CYP2C19 Polymorphisms and Clinical Outcomes Following Percutaneous Coronary Intervention (PCI) in the Million Veterans Program. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.25.23297578. [PMID: 37961335 PMCID: PMC10635203 DOI: 10.1101/2023.10.25.23297578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background CYP2C19 loss-of-function (LOF) alleles decrease the antiplatelet effect of clopidogrel following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). The impact of genotype in stable ischemic heart disease (SIHD) is unclear. Objectives Determine the association of CYP2C19 genotype with major adverse cardiac events (MACE) after PCI for ACS or SIHD. Methods Million Veterans Program (MVP) participants age <65 years with a PCI documented in the VA Clinical Assessment, Reporting and Tracking (CART) Program between 1/1/2009 to 9/30/2017, treated with clopidogrel were included. Time to MACE defined as the composite of all-cause death, stroke or myocardial infarction within 12 months following PCI. Results Among 4,461 Veterans (mean age 59.1 ± 5.1 years, 18% Black); 44% had ACS, 56% had SIHD and 29% carried a CYP2C19 LOF allele. 301 patients (6.7%) experienced MACE while being treated with clopidogrel, 155 (7.9%) in the ACS group and 146 (5.9%) in the SIHD group. Overall, MACE was not significantly different between LOF carriers vs. noncarriers (adjusted hazard ratio [HR] 1.18, confidence interval [95%CI] 0.97-1.45, p=0.096). Among patients presenting with ACS, MACE risk in LOF carriers versus non-carriers was numerically higher (HR 1.30, 95%CI 0.98-1.73, p=0.067). There was no difference in MACE risk in patients with SIHD (HR 1.09, 95%CI 0.82-1.44; p=0.565). Conclusions CYP2C19 LOF carriers presenting with ACS treated with clopidogrel following PCI experienced a numerically greater elevated risk of MACE events. CYP2C19 LOF genotype is not associated with MACE among patients presenting with SIHD.
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Affiliation(s)
| | - Kevin A. Friede
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mary E. Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Kyung Min Lee
- VA Salt Lake City Heath Care System, Salt Lake City, UT
| | - Zhenyu Lu
- VA Salt Lake City Heath Care System, Salt Lake City, UT
| | - Julie A. Lynch
- VA Salt Lake City Heath Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott L. DuVall
- VA Salt Lake City Heath Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jason L. Vassy
- VA Boston Healthcare System, Harvard Medical School, and Brigham and Women’s Hospital, Boston, MA
| | - Stephen W. Waldo
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
- Rocky Mountain Regional VA Medical Center and University of Colorado School of Medicine, Aurora, CO
| | | | - Thomas M. Maddox
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel J. Rader
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Scott M. Damrauer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Philip S. Tsao
- VA Palo Alto Healthcare System and Stanford University, Palo Alto, CA
| | - Kyong-Mi Chang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Deepak Voora
- Durham VA Healthcare System and Duke University, Durham, NC
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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24
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Capodanno D, Angiolillo DJ. Personalised antiplatelet therapies for coronary artery disease: what the future holds. Eur Heart J 2023; 44:3059-3072. [PMID: 37345589 DOI: 10.1093/eurheartj/ehad362] [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: 03/05/2023] [Revised: 05/07/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023] Open
Abstract
Coronary artery disease (CAD) is one of the leading causes of death globally, and antiplatelet therapy is crucial for both its prevention and treatment. Antiplatelet drugs such as aspirin and P2Y12 inhibitors are commonly used to reduce the risk of thrombotic events, including myocardial infarction, stroke, and stent thrombosis. However, the benefits associated with the use of antiplatelet drugs also come with a risk of bleeding complications. The ever-growing understanding of the poor prognostic implications associated with bleeding has set the foundations for defining strategies that can mitigate such safety concern without any trade-off in antithrombotic protection. To this extent, personalised antiplatelet therapy has emerged as a paradigm that optimizes the balance between safety and efficacy by customizing treatment to the individual patient's needs and risk profile. Accurate risk stratification for both bleeding and thrombosis can aid in selecting the optimal antiplatelet therapy and prevent serious and life-threatening outcomes. Risk stratification has traditionally included clinical and demographic characteristics and has expanded to incorporate angiographic features and laboratory findings. The availability of bedside platelet function testing as well as rapid genotyping assays has also allowed for a more individualized selection of antiplatelet therapy. This review provides a comprehensive overview of the current state of the art and future trends in personalised antiplatelet therapy for patients with CAD, with emphasis on those presenting with an acute coronary syndrome and undergoing percutaneous coronary revascularization. The aim is to provide clinicians with a comprehensive understanding of personalised antiplatelet therapy and facilitate informed clinical decision-making.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria 'G. Rodolico - San Marco', University of Catania, Via Santa Sofia, 78 - 95123 Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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25
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Narasimhalu K, Mayerhofer E, Parodi L, Georgakis MK, De Silva DA, Rosand J, Anderson CD. The ABCD-GENE score influences vascular event rates in both users of clopidogrel and aspirin, as well as non-users of either drug in a population-based cohort study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.06.23293732. [PMID: 37609315 PMCID: PMC10441502 DOI: 10.1101/2023.08.06.23293732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background and Objectives Clopidogrel is an antiplatelet used in both primary and secondary prevention of cardiovascular diseases. It is a prodrug, requiring CYP2C19 for its metabolism to the active metabolite. The ABCD-GENE score, combining clinical attributes (age, body mass index, chronic kidney disease, diabetes mellitus), with genetic information (presence of 1 or 2 loss of function (LOF) alleles in the CYP2C19 gene) has been shown to identify patients with higher risk of recurrent cardiovascular events in high-risk populations undergoing percutaneous coronary intervention. We aimed to determine if the ABCD-GENE score or LOF alleles were associated with an increased risk of vascular events among clopidogrel users in a general population. Methods We conducted a population based cohort study with UK Biobank's primary care prescription records to identify clopidogrel users. ABCD-GENE scores were calculated with closest available data from the first date of clopidogrel prescription. The number of LOF alleles present, and the clinical component ABCD, were separate exposures. The outcome of interest was a composite endpoint of vascular events comprised of myocardial infarction, ischemic stroke, and death due to either of these. We performed Cox proportional hazards models with clopidogrel as a time varying exposure to predict hazards of these outcomes. In order to determine the drug specificity of these exposures, the analyses were repeated in aspirin users, and in non-users of either aspirin or clopidogrel. Results Among 11,248 clopidogrel users, 3,365 (30%) developed a vascular event over a mean follow-up of 5.95±3.94 years. ABCD-GENE score ≥10 was associated with an increased risk of vascular events (HR 1.13, 95% CI 1.03-1.23). In aspirin users, and in non-users of either aspirin or clopidogrel, the ABCD-GENE score was also associated with increased risk of vascular events. In clopidogrel users, aspirin users, and non-users of either drug, the ABCD score was associated with increased risk of vascular events. The presence of two CYP2C19 LOF alleles was associated with an increased risk of vascular events in aspirin and non-users but not in clopidogrel users. Discussion In this population-based cohort study, the ABCD-GENE score was associated with an increased risk of vascular events in clopidogrel users, aspirin users, and in non-users of either drug. The clinical component, ABCD was also associated with an increased risk of vascular events in all three groups. This suggests that the ABCD-GENE score is not specific to clopidogrel users in identifying persons at high risk of vascular events in a general sample with low baseline CYP2C19 LOF allele frequency.
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Affiliation(s)
- Kaavya Narasimhalu
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Ernst Mayerhofer
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Livia Parodi
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Marios K Georgakis
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Deidre Anne De Silva
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, MA, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
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26
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Oni-Orisan A, Tuteja S, Hoffecker G, Smith DM, Castrichini M, Crews KR, Murphy WA, Nguyen NHK, Huang Y, Lteif C, Friede KA, Tantisira K, Aminkeng F, Voora D, Cavallari LH, Whirl-Carrillo M, Duarte JD, Luzum JA. An Introductory Tutorial on Cardiovascular Pharmacogenetics for Healthcare Providers. Clin Pharmacol Ther 2023; 114:275-287. [PMID: 37303270 PMCID: PMC10406163 DOI: 10.1002/cpt.2957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/17/2023] [Indexed: 06/13/2023]
Abstract
Pharmacogenetics can improve clinical outcomes by reducing adverse drug effects and enhancing therapeutic efficacy for commonly used drugs that treat a wide range of cardiovascular diseases. One of the major barriers to the clinical implementation of cardiovascular pharmacogenetics is limited education on this field for current healthcare providers and students. The abundance of pharmacogenetic literature underscores its promise, but it can also be challenging to learn such a wealth of information. Moreover, current clinical recommendations for cardiovascular pharmacogenetics can be confusing because they are outdated, incomplete, or inconsistent. A myriad of misconceptions about the promise and feasibility of cardiovascular pharmacogenetics among healthcare providers also has halted clinical implementation. Therefore, the main goal of this tutorial is to provide introductory education on the use of cardiovascular pharmacogenetics in clinical practice. The target audience is any healthcare provider (or student) with patients that use or have indications for cardiovascular drugs. This tutorial is organized into the following 6 steps: (1) understand basic concepts in pharmacogenetics; (2) gain foundational knowledge of cardiovascular pharmacogenetics; (3) learn the different organizations that release cardiovascular pharmacogenetic guidelines and recommendations; (4) know the current cardiovascular drugs/drug classes to focus on clinically and the supporting evidence; (5) discuss an example patient case of cardiovascular pharmacogenetics; and (6) develop an appreciation for emerging areas in cardiovascular pharmacogenetics. Ultimately, improved education among healthcare providers on cardiovascular pharmacogenetics will lead to a greater understanding for its potential in improving outcomes for a leading cause of morbidity and mortality.
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Affiliation(s)
- Akinyemi Oni-Orisan
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Glenda Hoffecker
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - D. Max Smith
- MedStar Health, Columbia, Maryland, USA
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Matteo Castrichini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristine R. Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - William A. Murphy
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nam H. K. Nguyen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Yimei Huang
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Christelle Lteif
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kevin A. Friede
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kelan Tantisira
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Folefac Aminkeng
- Departments of Medicine and Biomedical Informatics (DBMI), Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
- Centre for Precision Health (CPH), National University Health System (NUHS), Singapore City, Singapore
| | - Deepak Voora
- Precision Medicine Program, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Center for Individualized and Genomic Medicine Research, Henry Ford Health System, Detroit, Michigan, 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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Lee YC, Liao YC, Lin CJ, Chung CP. Baseline P2Y12 reactivity, kidney function, and CYP2C19 genotype determine clopidogrel responsiveness in acute stroke. Sci Rep 2023; 13:8085. [PMID: 37208337 DOI: 10.1038/s41598-023-34481-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 05/02/2023] [Indexed: 05/21/2023] Open
Abstract
Clopidogrel is the most-widely used platelet P2Y12-inhibitor for secondary-prevention of ischemic stroke. Platelet P2Y12 reactivity before and after inhibitors can be measured with blood sampling by commercialized system. We aimed to evaluate (1) whether high-on-clopidogrel platelet P2Y12 reactivity (HCPR) is associated with short-term vascular events and (2) the predictors of HCPR in acute stroke. The inclusion criterion was patients with acute stroke who received clopidogrel within 12-48 h after the onset. Platelet reactivity was assayed at baseline and after clopidogrel treatment using the VerifyNow system. The primary endpoint was recurrent ischemic events within 21 days after stroke. Among 190 patients, 32(16.9%) had recurrent ischemic stroke. Multivariate analyses showed that HCPR was significantly associated with the short-term events with an odds-ratio of 2.5 (95% CI 1.1-5.7, p = 0.027). Patients with HCPR had significantly higher frequencies of high baseline platelet P2Y12 reactivity, impaired kidney function, and carrying one or two CYP2C19 loss-of-function alleles. A poor clopidogrel response score combining these factors was developed. Ten percent of patients with score 0, 20.3% of those with score 1, 38.3% of those with score 2, and 66.7% of those with score 3 had HCPR (χ2-test, p < 0.001). Multivariate analyses showed that, compared with the score-0 group, the score-2 and -3 groups had higher risks of HCPR with hazard-ratios of 5.4 (95% CI 1.5-20.3, p = 0.012) and 17.4 (95% CI 3.4-88.9, p = 0.001) for developing recurrent ischemic strokes. The study emphasized the role of HCPR in ischemic stroke. We also developed an HCPR risk score, which could be used in clinical practice or trials, potentially with more precision, to weigh the clinical benefit of a tailored antiplatelet-strategy for patients with stroke.
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Affiliation(s)
- Yi-Chung Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
| | - Yi-Chu Liao
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan.
- Department of Neurology, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan.
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29
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Galli M, Angiolillo DJ. How is pharmacogenetics changing clinical trial design for percutaneous coronary intervention? Expert Rev Clin Pharmacol 2023; 16:383-385. [PMID: 37060346 DOI: 10.1080/17512433.2023.2203381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/12/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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30
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Yeh JS, Chen WT, Tomlinson B, Tam WC, Chien LN. Comparing the effectiveness and safety of dual antiplatelet with ticagrelor or clopidogrel in elderly Asian patients with acute myocardial infraction. Front Cardiovasc Med 2023; 10:1143509. [PMID: 37008324 PMCID: PMC10060791 DOI: 10.3389/fcvm.2023.1143509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
BackgroundCurrent guidelines recommend potent P2Y12 inhibitors for patients after acute coronary syndrome. However, the data on the efficacy and safety of potent P2Y12 inhibitors in elderly Asian populations was limited. We aimed to investigate the major adverse cardiovascular events (MACE), bleeding events, and net adverse clinical events (NACE) with ticagrelor and clopidogrel in Taiwanese patients aged 65 and older after acute myocardial infarction (AMI).MethodsThis retrospective population-based cohort study was conducted using data from the National Health Insurance Research Database. The AMI patients aged ≥65 years who underwent percutaneous coronary intervention (PCI) and survived after 1 month were included. The patients were separated into 2 cohorts depending on the type of dual antiplatelet therapy (DAPT) they received: ticagrelor plus aspirin (T + A) or clopidogrel plus aspirin (C + A). We used inverse probability of treatment weighting to balance the difference between these 2 study groups. The outcome included all-cause mortality, MACE (cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction), intracerebral hemorrhage, major bleeding, and NACE which is composed of cardiovascular death, ischemic and hemorrhagic events. The follow-up period was up to 12 months.ResultsFrom 2013 to 2017, a total of 14,715 patients who met the eligibility criteria were separated into 2 groups: 5,051 for T + A and 9,664 for C + A. Compared to patients with C + A, patients who received T + A had a lower risk of cardiovascular death and all-cause death, with an adjusted HR of 0.57 [95% confidence interval (CI), 0.38–0.85, p = 0.006] and 0.58 (95% CI 0.45–0.74, p < 0.001), respectively. No differences were found in MACE, intracranial and major bleeding between the 2 groups. In addition, the patients with T + A had a lower risk of NACE with an adjusted HR of 0.86 (95% CI 0.74–1.00, p = 0.045)ConclusionAmong elderly AMI patients receiving DAPT after successful PCI, ticagrelor was a more favorable P2Y12 inhibitor than clopidogrel because of lowering the risk of death and NACE without increasing the risk of severe bleeding. Ticagrelor is an effective and safe P2Y12 inhibitor in Asian elderly survivors after PCI.
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Affiliation(s)
- Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Ting Chen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macao SAR, China
| | - Weng-Chio Tam
- Department of Cardiology, Centro Hospitalar Conde São Januário, Macao SAR, China
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Correspondence: Li-Nien Chien
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31
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Harik L, Perezgrovas-Olaria R, Soletti G, Dimagli A, Alzghari T, An KR, Cancelli G, Gaudino M, Sandner S. Graft thrombosis after coronary artery bypass surgery and current practice for prevention. Front Cardiovasc Med 2023; 10:1125126. [PMID: 36970352 PMCID: PMC10031065 DOI: 10.3389/fcvm.2023.1125126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide. The reported incidence of graft failure ranges between 10% and 50%, depending upon the type of conduit used. Thrombosis is the predominant mechanism of early graft failure, occurring in both arterial and vein grafts. Significant advances have been made in the field of antithrombotic therapy since the introduction of aspirin, which is regarded as the cornerstone of antithrombotic therapy for prevention of graft thrombosis. Convincing evidence now exists that dual antiplatelet therapy (DAPT), consisting of aspirin and a potent oral P2Y12 inhibitor, effectively reduces the incidence of graft failure. However, this is achieved at the expense of an increase in clinically important bleeding, underscoring the importance of balancing thrombotic risk and bleeding risk when considering antithrombotic therapy after CABG. In contrast, anticoagulant therapy has proved ineffective at reducing the occurrence of graft thrombosis, pointing to platelet aggregation as the key driver of graft thrombosis. We provide a comprehensive review of current practice for prevention of graft thrombosis and discuss potential future concepts for antithrombotic therapy including P2Y12 inhibitor monotherapy and short-term DAPT.
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Affiliation(s)
- Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | | | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Kevin R. An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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32
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Thomas CD, Williams AK, Lee CR, Cavallari LH. Pharmacogenetics of P2Y 12 receptor inhibitors. Pharmacotherapy 2023; 43:158-175. [PMID: 36588476 PMCID: PMC9931684 DOI: 10.1002/phar.2758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/03/2023]
Abstract
Oral P2Y12 inhibitors are commonly prescribed for cardiovascular disease and include clopidogrel, prasugrel, and ticagrelor. Each of these drugs has its strengths and weaknesses. Prasugrel and ticagrelor are more potent inhibitors of platelet aggregation and were shown to be superior to clopidogrel in preventing major adverse cardiovascular events after an acute coronary syndrome and percutaneous coronary intervention (PCI) in the absence of genotyping. However, both are associated with an increased risk for non-coronary artery bypass-related bleeding. Clopidogrel is a prodrug requiring bioactivation, primarily via the CYP2C19 enzyme. Approximately 30% of individuals have a CYP2C19 no function allele and decreased or no CYP2C19 enzyme activity. Clopidogrel-treated carriers of a CYP2C19 no function allele have decreased exposure to the clopidogrel active metabolite and lesser inhibition of platelet aggregation, which likely contributed to reduced clopidogrel efficacy in clinical trials. The pharmacogenetic data for clopidogrel are most robust in the setting of PCI, but evidence is accumulating for other indications. Guidance is available from expert consensus groups and regulatory agencies to assist with integrating genetic information into P2Y12 inhibitor prescribing decisions, and CYP2C19 genotype-guided antiplatelet therapy after PCI is one of the most common examples of clinical pharmacogenetic implementation. Herein, we review the evidence for pharmacogenetic associations with clopidogrel response and outcomes with genotype-guided P2Y12 inhibitor selection and describe guidance to assist with pharmacogenetic implementation. We also describe processes for applying genotype data for P2Y12 inhibitor therapy selection and remaining gaps in the field. Ultimately, consideration of both clinical and genetic factors may guide selection of P2Y12 inhibitor therapy that optimally balances the atherothrombotic and bleeding risks.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Saito Y, Oyama K, Tsujita K, Yasuda S, Kobayashi Y. Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond. J Cardiol 2023; 81:168-178. [PMID: 35882613 DOI: 10.1016/j.jjcc.2022.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 10/16/2022]
Abstract
Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Kazuma Oyama
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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34
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Yamamoto K, Watanabe H, Morimoto T, Obayashi Y, Natsuaki M, Yamaji K, Domei T, Ogita M, Ohya M, Tatsushima S, Suzuki H, Tada T, Ishii M, Nikaido A, Watanabe N, Fujii S, Mori H, Nishikura T, Suematsu N, Hayashi F, Komiyama K, Shigematsu T, Isawa T, Suwa S, Ando K, Kimura T. Clopidogrel Monotherapy After 1-Month Dual Antiplatelet Therapy in Patients With Diabetes Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:19-31. [PMID: 36599584 DOI: 10.1016/j.jcin.2022.09.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/08/2022] [Accepted: 09/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetes was reported to be associated with an impaired response to clopidogrel. OBJECTIVES The aim of this study was to evaluate the safety and efficacy of clopidogrel monotherapy after very short dual antiplatelet therapy (DAPT) in patients with diabetes undergoing percutaneous coronary intervention (PCI). METHODS A subgroup analysis was conducted on the basis of diabetes in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2) Total Cohort (N = 5,997) (STOPDAPT-2, n = 3,009; STOPDAPT-2 ACS [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS], n = 2,988), which randomly compared 1-month DAPT followed by clopidogrel monotherapy with 12-month DAPT with aspirin and clopidogrel after cobalt-chromium everolimus-eluting stent implantation. The primary endpoint was a composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (TIMI [Thrombolysis In Myocardial Infarction] major or minor) endpoints at 1 year. RESULTS There were 2,030 patients with diabetes (33.8%) and 3967 patients without diabetes (66.2%). Regardless of diabetes, the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (diabetes, 3.58% vs 4.12% [HR: 0.87; 95% CI: 0.56-1.37; P = 0.55]; nondiabetes, 2.46% vs 2.49% [HR: 0.99; 95% CI: 0.67-1.48; P = 0.97]; Pinteraction = 0.67) and for the cardiovascular endpoint (diabetes, 3.28% vs 3.05% [HR: 1.10; 95% CI: 0.67-1.81; P = 0.70]; nondiabetes, 1.95% vs 1.43% [HR: 1.38; 95% CI: 0.85-2.25; P = 0.20]; Pinteraction = 0.52), while it was lower for the bleeding endpoint (diabetes, 0.30% vs 1.50% [HR: 0.20; 95% CI: 0.06-0.68; P = 0.01]; nondiabetes, 0.61% vs 1.21% [HR: 0.51; 95% CI: 0.25-1.01; P = 0.054]; Pinteraction = 0.19). CONCLUSIONS Clopidogrel monotherapy after 1-month DAPT compared with 12-month DAPT reduced major bleeding events without an increase in cardiovascular events regardless of diabetes, although the findings should be considered as hypothesis generating, especially in patients with acute coronary syndrome, because of the inconclusive result in the STOPDAPT-2 ACS trial. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498).
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. https://twitter.com/KoYamamoto7
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. https://twitter.com/HirotWatanabeMD
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shojiro Tatsushima
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hirohiko Suzuki
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akira Nikaido
- Department of Cardiology, Minamino Cardiovascular Hospital, Hachioji, Japan
| | - Naoki Watanabe
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Shinya Fujii
- Department of Cardiology, Sendai Cardiovascular Center, Sendai, Japan
| | - Hiroyoshi Mori
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Tenjin Nishikura
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Nobuhiro Suematsu
- Division of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Fujio Hayashi
- Division of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Kota Komiyama
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Tatsuya Shigematsu
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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35
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Marcucci R, Berteotti M, Gragnano F, Galli M, Cavallari I, Renda G, Capranzano P, Santilli F, Capodanno D, Angiolillo DJ, Cirillo P, Calabrò P, Patti G, De Caterina R. Monitoring antiplatelet therapy: where are we now? J Cardiovasc Med (Hagerstown) 2022; 24:e24-e35. [PMID: 36729588 DOI: 10.2459/jcm.0000000000001406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Single antiplatelet therapy represents the cornerstone of thrombosis prevention in atherosclerotic cardiovascular disease. Dual antiplatelet therapy (DAPT), consisting of aspirin plus a P2Y12 inhibitor, is the standard of care for patients with acute coronary syndrome or undergoing both coronary and peripheral percutaneous interventions. Recent data suggest the efficacy of DAPT also after minor stroke. In this setting, a large body of evidence has documented that genetic and acquired patients' characteristics may affect the magnitude of platelet inhibition induced by antiplatelet agents. The implementation of tools allowing the identification and prediction of platelet inhibition has recently been shown to improve outcomes, leading to an optimal balance between antithrombotic efficacy and bleeding risk. We are therefore clearly moving towards tailored antiplatelet therapy. The aim of this paper is to summarize the available evidence on the evaluation of platelet inhibition in patients with coronary, peripheral, or cerebrovascular atherosclerosis. We will here focus on antiplatelet therapy based on both aspirin and P2Y12 inhibitors. In addition, we provide practical insights into the clinical settings in which it appears reasonable to implement antiplatelet therapy monitoring.
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Affiliation(s)
- Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Martina Berteotti
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Felice Gragnano
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome.,Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | | | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara
| | - Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Francesca Santilli
- Department of Medicine and Aging, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples
| | - Paolo Calabrò
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Giuseppe Patti
- Maggiore della Carità Hospital, University of Eastern Piedmont, Novara
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa.,Division of Cardiology, Azienda Ospedaliero-Universitaria Pisana, Pisa.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Pescara, Italy
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Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [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: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
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Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Zhao X, Ma S, Kang Y, Tang C, Liu B, Jiang H, Zheng M, Tang Y, Sun H, Liu Y, Lai X, Gong Y, Li Y, Qi Z, Ren L, Li J, Li Y, Han Y. Antiplatelet effect, safety, and pharmacokinetics of vicagrel in patients with coronary artery disease undergoing percutaneous coronary intervention. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:806-814. [PMID: 35438151 DOI: 10.1093/ehjcvp/pvac026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/13/2022] [Accepted: 04/17/2022] [Indexed: 12/29/2022]
Abstract
AIMS Vicagrel, a novel antiplatelet prodrug to overcome the residual high platelet reactivity of clopidogrel induced by inactive metabolism and cytochrome P450 (CYP) 2C19 polymorphisms, provides favourable antiplatelet inhibition in healthy volunteers. However, its antiplatelet effect and safety in patients with coronary artery disease (CAD) are unclear. METHODS AND RESULTS This was a multicentre, randomized, double-blind, triple-dummy, dose-exploring phase II trial comparing the antiplatelet activity and safety of vicagrel at different doses vs. those of clopidogrel in patients with CAD undergoing percutaneous coronary intervention (PCI). The primary endpoint was inhibition of adenosine diphosphate (ADP)-induced platelet aggregation (%IPA) after loading and maintenance doses (LD/MD) at 28 days. Safety endpoints included adverse events (AEs) and Bleeding Academic Research Consortium-defined any bleeding. Pharmacokinetic (PK) profiles and the influence of CYP2C19 polymorphisms were explored in subgroup analysis. Two hundred and seventy-nine patients diagnosed with stable CAD (51.97%), unstable angina (40.86%), and myocardial infarction (7.17%) were randomized to receive vicagrel 20/5 mg (LD/MD), 24/6 mg, or 30/7.5 mg or clopidogrel 300/75 mg in combination with aspirin. %IPAs on Day 28 were 30.19%, 35.02%, 45.61%, and 32.55% for vicagrel 20/5, 24/6, and 30/7.5 mg and clopidogrel, respectively, and were comparable across all groups (P = 0.0694). The plasma concentration of the vicagrel active metabolite M15-2 had a similar area under curve and Tmax to those of clopidogrel. There were no significant differences in AEs (4.35%, 0%, 1.45%, and 5.56% for vicagrel 20/5, 24/6, and 30/7.5 mg and clopidogrel, P = 0.6667) or any bleeding (13.04%, 14.06%, 11.59%, and 11.11% for vicagrel 20/5, 24/6, and 30/7.5 mg and clopidogrel, respectively, P = 0.95) across four groups. %IPAs and PK profiles of vicagrel did not vary significantly among different CYP2C19 metabolizers. CONCLUSION Vicagrel had comparable antiplatelet effect and safety to clopidogrel in patients with CAD undergoing PCI.
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Affiliation(s)
- Xin Zhao
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China.,Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Yi Kang
- Department of Heart Center, First Hospital of Tsinghua University, Beijing, China
| | - Chengchun Tang
- Department of Cardiology, Zhongda Hospital Southeast University, Nanjing, Jiangsu, China
| | - Bin Liu
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Hong Jiang
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Mingqi Zheng
- Department of Cardiology, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yu Tang
- Department of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
| | - Hongbin Sun
- State Key Laboratory of Natural Medicines and Center of Drug Discovery, College of Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yongqiang Liu
- R&D Department, Jiangsu Vcare PharmaTech Co., Ltd, Nanjing, Jiangsu, China
| | - Xiaojuan Lai
- R&D Department, Jiangsu Vcare PharmaTech Co., Ltd, Nanjing, Jiangsu, China
| | - Yanchun Gong
- R&D Department, Jiangsu Vcare PharmaTech Co., Ltd, Nanjing, Jiangsu, China
| | - Yongguo Li
- R&D Department, Guangzhou JOYO Pharma Ltd, Guangzhou, Guangdong, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China
| | - Ling Ren
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China
| | - Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning, China
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Jin Y, Ma J, Wang Z, Zou Y, Wang G, Wu Y, Wang Y, Liu H, Yin T, Ye P. Performance of the ABCD-GENE Score for Predicting Clinical Outcomes in Clopidogrel-Treated Patients with ACS. J Cardiovasc Transl Res 2022; 15:1385-1392. [PMID: 35437618 DOI: 10.1007/s12265-022-10255-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/04/2022] [Indexed: 12/16/2022]
Abstract
The ABCD-GENE score was constructed to identify patients with high platelet reactivity (HPR) after 30 days of clopidogrel treatment. In our study, 1297 eligible patients with acute coronary syndrome (ACS) were included, and 44 (3.4%) major adverse cardiovascular events (MACEs) occurred during the 12-month clopidogrel treatment. The score with a cutoff of ≥ 10 was independently associated with the risk of 5-day HPR (adjusted HR: 1.73, 95% CI: 1.09-2.74, P = 0.020) and MACEs (adjusted HR: 2.25, 95% CI: 1.19-4.25, P = 0.013). The risk of MACEs increased when the multivariable model with the score (≥ 10) plus 5-day HPR was used (adjusted HR: 4.37, 95% CI: 1.90-10.10, P = 0.001). The c-statistic for MACEs was 0.60 when using the score threshold of ≥ 10 and 0.63 when using the model with the score plus 5-day HPR. As a simple tool, the ABCD-GENE score could identify clopidogrel-treated Chinese patients with ACS who are at increased risk of MACEs. The addition of 5-day HPR could slightly improve the diagnostic ability of the score.
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Affiliation(s)
- Ying Jin
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
- Department of Geriatrics, Air Force Medical Center of Chinese PLA, Beijing, 100141, China
| | - Jing Ma
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of Chinese PLA General Hospital, Beijing, 100142, China
| | - Ziqian Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Yuting Zou
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Guanyun Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Yangxun Wu
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Yuyan Wang
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Haiping Liu
- Medical School of Chinese PLA, Beijing, 100853, China
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Tong Yin
- Medical School of Chinese PLA, Beijing, 100853, China.
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China.
| | - Ping Ye
- Medical School of Chinese PLA, Beijing, 100853, China.
- Institute of Geriatrics and Department of Cardiology, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese, PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China.
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P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:829-844. [PMID: 35697777 DOI: 10.1038/s41569-022-00725-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 12/15/2022]
Abstract
For 20 years, dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and a platelet P2Y12 receptor inhibitor, has been the gold standard of antithrombotic pharmacology after percutaneous coronary intervention (PCI). In the past 5 years, several investigations have challenged this paradigm by testing the efficacy and safety of P2Y12 inhibitor monotherapy (that is, without aspirin) following a short course of DAPT. Collectively, these studies suggested a reduction in the risk of major bleeding and no significant increase in thrombotic or ischaemic events compared with guideline-recommended DAPT. Current recommendations are evolving to inform clinical practice on the ideal candidates for P2Y12 inhibitor monotherapy after PCI. Generalizing the results of studies of P2Y12 inhibitor monotherapy requires a thorough understanding of their design, populations, interventions, comparators and results. In this Review, we provide an up-to-date overview on the use of P2Y12 inhibitor monotherapy after PCI, including supporting pharmacodynamic and clinical evidence, practical recommendations and future directions.
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Lee CR, Luzum JA, Sangkuhl K, Gammal RS, Sabatine MS, Stein CM, Kisor DF, Limdi NA, Lee YM, Scott SA, Hulot JS, Roden DM, Gaedigk A, Caudle KE, Klein TE, Johnson JA, Shuldiner AR. Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 Genotype and Clopidogrel Therapy: 2022 Update. Clin Pharmacol Ther 2022; 112:959-967. [PMID: 35034351 PMCID: PMC9287492 DOI: 10.1002/cpt.2526] [Citation(s) in RCA: 161] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
CYP2C19 catalyzes the bioactivation of the antiplatelet prodrug clopidogrel, and CYP2C19 genotype impacts clopidogrel active metabolite formation. CYP2C19 intermediate and poor metabolizers who receive clopidogrel experience reduced platelet inhibition and increased risk for major adverse cardiovascular and cerebrovascular events. This guideline is an update to the 2013 Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for the use of clopidogrel based on CYP2C19 genotype and includes expanded indications for CYP2C19 genotype-guided antiplatelet therapy, increased strength of recommendation for CYP2C19 intermediate metabolizers, updated CYP2C19 genotype to phenotype translation, and evidence from an expanded literature review (updates at www.cpicpgx.org).
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Affiliation(s)
- Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Katrin Sangkuhl
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Roseann S. Gammal
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Marc S. Sabatine
- Thrombolysis in Myocardial Infarction Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - C. Michael Stein
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David F. Kisor
- Department of Pharmaceutical Sciences, Manchester University, Fort Wayne, IN, USA
| | - Nita A Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yee Ming Lee
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Stuart A. Scott
- Department of Pathology, Stanford University, Stanford, CA, USA; Clinical Genomics Laboratory, Stanford Health Care, Palo Alto, CA, USA
| | - Jean-Sébastien Hulot
- Université de Paris, CIC1418 and DMU CARTE, AP-HP, Hôpital Européen Georges-Pompidou, F-75015, Paris, France
| | - Dan M. Roden
- Departments of Medicine and Pharmacology, Office of Personalized Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Andrea Gaedigk
- Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children’s Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Kelly E. Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Teri E. Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Alan R. Shuldiner
- Department of Medicine, and Program for Genomic and Personalized Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Lee SJ, Cha JJ, Jeong YH, Hong SJ, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y, Joo HJ, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Kim HS, Kim MH, Shin ES, Lim DS, Kim BK. Platelet Reactivity and Clinical Outcomes After Drug-Eluting Stent Implantation. JACC Cardiovasc Interv 2022; 15:2253-2265. [DOI: 10.1016/j.jcin.2022.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/11/2022] [Accepted: 09/06/2022] [Indexed: 11/22/2022]
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Escalation and De-Escalation of Antiplatelet Therapy after Acute Coronary Syndrome or PCI: Available Evidence and Implications for Practice. J Clin Med 2022; 11:jcm11216246. [PMID: 36362474 PMCID: PMC9654330 DOI: 10.3390/jcm11216246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard for the antithrombotic management of patients with an acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Implementation of intensified or prolonged DAPT regimens has proven to lower the risk of ischemic events but at the expense of increased bleeding. Importantly, bleeding is a predictor of poor prognosis. Risk stratification and selection of tailored antiplatelet strategies to maximize the net clinical benefit in individual patients with ACS or undergoing PCI is therefore potentially beneficial. Recently, novel approaches including DAPT de-escalation or escalation have been proposed as possible alternatives to standard DAPT. These strategies, which are generally based on patient's risk profile, genetics, and/or platelet function have been proposed to offer more tailored treatments in patients with ACS or PCI, with the ultimate goal of providing adequate ischemic protection while mitigating the risk of bleeding. This review summarizes the available evidence on DAPT de-escalation or escalation (both guided and unguided) and discusses the practical implications of these strategies in the contemporary management of patients with ACS and/or undergoing PCI.
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Zhou X, Angiolillo DJ, Ortega-Paz L. P2Y 12 Inhibitor Monotherapy after Percutaneous Coronary Intervention. J Cardiovasc Dev Dis 2022; 9:jcdd9100340. [PMID: 36286292 PMCID: PMC9604207 DOI: 10.3390/jcdd9100340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
In patients with acute and chronic coronary artery disease undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) has been the cornerstone of pharmacotherapy for the past two decades. Although its antithrombotic benefit is well established, DAPT is associated with an increased risk of bleeding, which is independently associated with poor prognosis. The improvement of the safety profiles of drug-eluting stents has been critical in investigating and implementing shorter DAPT regimens. The introduction into clinical practice of newer generation oral P2Y12 inhibitors such as prasugrel and ticagrelor, which provide more potent and predictable platelet inhibition, has questioned the paradigm of standard DAPT durations after coronary stenting. Over the last five years, several trials have assessed the safety and efficacy of P2Y12 inhibitor monotherapy after a short course of DAPT in patients treated with PCI. Moreover, ongoing studies are testing the role of P2Y12 inhibitor monotherapy immediately after PCI in selected patients. In this review, we provide up-to-date evidence on the efficacy and safety of P2Y12 inhibitor monotherapy after a short period of DAPT compared to DAPT in patients undergoing PCI as well as outcomes associated with P2Y12 inhibitor monotherapy compared to aspirin for long-term prevention.
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Affiliation(s)
- Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Department of Internal Medicine, University of Alabama at Birmingham Montgomery, Montgomery, AL 36116, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Correspondence: ; Tel.: +1-904-244-3378; Fax: +1-904-244-3102
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Mazzone PM, Angiolillo DJ, Capodanno D. Approaches to de-escalation of antiplatelet treatment in stabilized post-myocardial infarction patients with high ischemic risk. Expert Rev Cardiovasc Ther 2022; 20:839-849. [DOI: 10.1080/14779072.2022.2137492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
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Liang B, Li R, Lu J, Tian XJ, Gu N. Tongue diagnostic parameters-based diagnostic signature in coronary artery disease patients with clopidogrel resistance after percutaneous coronary intervention. Explore (NY) 2022:S1550-8307(22)00202-6. [DOI: 10.1016/j.explore.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/20/2022] [Accepted: 10/25/2022] [Indexed: 11/15/2022]
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Kunadian V, Baber U, Pivato CA, Cao D, Dangas G, Sartori S, Zhang Z, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Dehghani P, Mehta S, Moliterno DJ, Ohman EM, Escaned J, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Džavík V, Gurbel P, Hamm CW, Henry T, Kastrati A, Marx SO, Oldroyd K, Steg PG, Pocock S, Mehran R. Bleeding and Ischemic Outcomes With Ticagrelor Monotherapy According to Body Mass Index. JACC Cardiovasc Interv 2022; 15:1948-1960. [DOI: 10.1016/j.jcin.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 01/09/2023]
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47
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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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Lahu S, Behnes M, Ndrepepa G, Neumann FJ, Sibbing D, Bernlochner I, Menichelli M, Mayer K, Richardt G, Gewalt S, Angiolillo DJ, Coughlan JJ, Aytekin A, Witzenbichler B, Hochholzer W, Cassese S, Kufner S, Xhepa E, Sager HB, Joner M, Fusaro M, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A, Akin I. Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:747-755. [PMID: 34961732 DOI: 10.1016/j.rec.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES The efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI. METHODS Patients (n=3987) were grouped into 3 categories: normal weight (BMI <25kg/m2; n=1084), overweight (BMI ≥ 25 to <30kg/m2; n=1890), and obesity (BMI ≥ 30kg/m2; n=1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding. RESULTS The primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P=.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P=.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P=.451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P=.990), overweight (5.6% vs 5.0%; P=.566) or obesity (4.4% vs 2.8%; P=.219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=.578) or secondary endpoint (Pint=.596). CONCLUSIONS In patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety. CLINICAL TRIAL REGISTRATION NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gjin Ndrepepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Cardiology, Klinik der Universität München, Ludwig - Maximilians - University, Munich, Germany
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | | | - Katharina Mayer
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gert Richardt
- Department of Cardiology and Angiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Senta Gewalt
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - John Joseph Coughlan
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alp Aytekin
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Salvatore Cassese
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Hendrik B Sager
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Joner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Massimiliano Fusaro
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | - Heribert Schunkert
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Stefanie Schüpke
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Adnan Kastrati
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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49
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Impact of diabetes mellitus on the pharmacodynamic effects of prasugrel and ticagrelor after switching from clopidogrel in patients with coronary artery disease. J Thromb Thrombolysis 2022; 54:461-469. [PMID: 36048358 DOI: 10.1007/s11239-022-02696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2022] [Indexed: 10/14/2022]
Abstract
Switching P2Y12 inhibitors is common in clinical practice. However, data on the pharmacodynamic (PD) effects of switching in clinical settings characterized by high platelet reactivity, such as diabetes mellitus (DM), are limited. This is a post-hoc analysis from a prospective, randomized, open-label study conducted in coronary artery disease patients comparing the PD effects of loading dose (LD) and maintenance dose regimens of prasugrel vs ticagrelor according to DM status. A total of 110 patients were enrolled: 42 (38%) with DM and 68 (62%) without DM. All patients were on maintenance dual antiplatelet therapy with aspirin and clopidogrel. PD assessments were performed using whole blood vasodilator-stimulated phosphoprotein (VASP), with results quantified by the platelet reactivity index (PRI), VerifyNow P2Y12 (VN-P2Y12) with results reported as P2Y12 reaction units (PRU), and light transmittance aggregometry (LTA) following 20 and 5 µM adenosine diphosphate stimuli with results reported as maximum platelet aggregation (MPA). PD assessments were performed at baseline (while on clopidogrel), 30 min after LD, 2 h after LD, and 1 week after LD. Overall, platelet reactivity was higher in DM than in non-DM patients while on clopidogrel therapy. After switching to either prasugrel or ticagrelor, platelet reactivity dropped but remained significantly higher among patients with DM at 30 min with all tests (VN-PRU p < 0.01, MPA 20 µM p < 0.01, VASP-PRI p = 0.02) and at 2 h with VN-PRU (p < 0.01) and LTA-MPA 20 µM (p < 0.01) but not with VASP-PRI (p = 0.19). There were no significant differences between prasugrel and ticagrelor both among patients with or without DM, except for lower LTA-MPA 20 at 30 min (p < 0.01) among non-DM patients treated with prasugrel. Patients with DM treated with clopidogrel have higher platelet reactivity compared to patients without DM. Although platelet reactivity markedly reduces to a similar extent after switching to prasugrel or ticagrelor, patients with DM persist with increased platelet reactivity compared to patients without DM.Study registration: ClinicalTrials.gov identifier: NCT01852175.
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50
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Scalia L, Calderone D, Capodanno D. Antiplatelet therapy after acute ischemic stroke or transient ischemic attack. Expert Rev Clin Pharmacol 2022; 15:1027-1038. [DOI: 10.1080/17512433.2022.2118713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Dario Calderone
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
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