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Millhuff AC, Blankenship JC. Strategies to optimize initial P2Y 12 inhibitor therapy in STEMI patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00671-7. [PMID: 39343662 DOI: 10.1016/j.carrev.2024.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 09/08/2024] [Accepted: 09/18/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care for patients who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI). Though this regimen reduces rates of ischemic events in patients with STEMI, the optimal strategy for P2Y12 administration in STEMI patients is still evolving. PURPOSE The purpose of this review is to summarize current evidence on optimal use of ticagrelor and prasugrel in the acute phase of STEMI. SUMMARY Due to high platelet activity in the acute setting of STEMI and PCI, adequate and rapid platelet inhibition is important. Strategies of increased ticagrelor/prasugrel loading dose or earlier administration in STEMI have not been successful in closing this platelet inhibition gap. Potential strategies for improving ticagrelor/prasugrel use early in STEMI include bridging with intravenous antiplatelet agents or crushed or chewed administration. CONCLUSION Oral ticagrelor/prasugrel given before or immediately after STEMI PCI is usually sufficient to prevent thrombotic complications. When faster platelet inhibition is desired, or oral administration is compromised by inability to swallow tablets, crushing/chewing ticagrelor/prasugrel tablets is an alternative to intravenous P2Y12 inhibitor therapy.
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Affiliation(s)
- Alexandra C Millhuff
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA.
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2
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Kang DY, Ahn JM, Park SJ, Park DW. Reply: Intravascular Imaging for Complex Coronary Intervention. J Am Coll Cardiol 2024; 83:e209. [PMID: 38777519 DOI: 10.1016/j.jacc.2024.03.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Do-Yoon Kang
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Niccoli G, Gurgoglione FL. It Is Time to Overcome the "One-Size-Fits-All" Approach in Chronic Coronary Syndrome? Am J Cardiol 2024; 219:114-115. [PMID: 38552711 DOI: 10.1016/j.amjcard.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/22/2024] [Indexed: 04/06/2024]
Affiliation(s)
- Giampaolo Niccoli
- Division of Cardiology, University of Parma, Parma University Hospital, Parma, Italy.
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Sun J, Jin X, Zhang L, Shen H, Yu H. Rosuvastatin plus ticagrelor decreases the risk of major adverse cardiovascular events and elevates cardiac function compared with ticagrelor alone in patients undergoing percutaneous coronary intervention: A meta‑analysis. Exp Ther Med 2023; 26:525. [PMID: 37869634 PMCID: PMC10587883 DOI: 10.3892/etm.2023.12224] [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: 03/29/2023] [Accepted: 09/13/2023] [Indexed: 10/24/2023] Open
Abstract
Several previous studies have reported that rosuvastatin plus ticagrelor is superior to ticagrelor monotherapy in patients receiving percutaneous coronary intervention (PCI); several others, however, dispute this. The present meta-analysis summarized relevant studies, aiming to comprehensively explore the efficacy of rosuvastatin plus ticagrelor vs. ticagrelor monotherapy in patients receiving PCI. Published studies comparing the efficacy between rosuvastatin plus ticagrelor and ticagrelor alone among patients receiving PCI were searched in the CNKI, Wanfang, CQVIP, EMBASE, Cochrane and PubMed databases until January 2023. The present meta-analysis included 3 cohort studies and 4 randomized controlled trials with 426 patients receiving rosuvastatin plus ticagrelor and 424 patients receiving ticagrelor monotherapy. Rosuvastatin plus ticagrelor decreased the occurrence of major adverse cardiovascular events (MACE) compared with ticagrelor [relative risk (RR), 0.29; 95% confidence interval (CI), 0.18-0.47]. Subgroup analysis revealed similar findings in studies with a follow-up of <6 months (RR, 0.24; 95% CI, 0.13-0.47) and ≥6 months (RR, 0.36; 95% CI, 0.18-0.70), as well as in studies using 10 mg rosuvastatin (RR, 0.27; 95% CI, 0.15-0.50) and 20 mg rosuvastatin (RR, 0.33; 95% CI, 0.16-0.69). In addition, rosuvastatin plus ticagrelor decreased the left ventricular (LV) end-systolic diameter [mean difference (MD), -0.71; 95% CI, -(1.36-0.07)], LV end-diastolic diameter [MD, -1.17; 95% CI, -(1.91-0.43)] and N-terminal pro-B-type natriuretic peptide [MD, -2.97; 95% CI, -(4.55-1.38)], and increased the LV ejection fraction (MD, 0.99; 95% CI, 0.74-1.25). In conclusion, rosuvastatin plus ticagrelor was shown to decrease the risk of MACE and elevate cardiac function compared with ticagrelor monotherapy in patients receiving PCI.
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Affiliation(s)
- Jinling Sun
- Department of Geriatrics, Zibo Central Hospital, Zibo, Shandong 255036, P.R. China
| | - Xiaodong Jin
- Department of Geriatrics, Zibo Central Hospital, Zibo, Shandong 255036, P.R. China
| | - Limei Zhang
- Department of Endocrinology, Zibo Central Hospital, Zibo, Shandong 255036, P.R. China
| | - Hongshuai Shen
- Department of Geriatrics, Zibo Central Hospital, Zibo, Shandong 255036, P.R. China
| | - Hui Yu
- Department of Endocrinology, Zibo Central Hospital, Zibo, Shandong 255036, P.R. China
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Wiens EJ, Leon SJ, Whitlock R, Tangri N, Shah AH. Ticagrelor as Compared to Clopidogrel Following Percutaneous Coronary Intervention for Acute Coronary Syndrome. Am J Cardiol 2023; 198:26-32. [PMID: 37196530 DOI: 10.1016/j.amjcard.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 05/19/2023]
Abstract
Dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 inhibitor has become a mainstay of therapy after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Although higher-potency P2Y12 inhibitors are preferred over clopidogrel in major society guidelines, recent evidence has questioned the extent of the benefit. It is important to evaluate the relative efficacy and safety of P2Y12 inhibitors in a real-world setting. This is a retrospective cohort study of all patients who underwent PCI for ACS in a Canadian province from January 1, 2015 to March 31, 2020. Baseline characteristics, including co-morbidities, medications, and bleeding risk, were obtained. Propensity matching was used to compare patients who received ticagrelor versus clopidogrel. The primary outcome was occurrence of major adverse cardiovascular events (MACEs) at 12 months, defined as death, nonfatal myocardial infarction, or unplanned revascularization. Secondary outcomes included all-cause mortality, major bleeding, stroke, and all-cause hospitalization. A total of 6,665 patients were included; 2,108 received clopidogrel and 4,214 received ticagrelor. Patients who received clopidogrel were older, had more co-morbidities, including cardiovascular risk factors, and had a higher bleeding risk. In 1.925 propensity score-matched pairs, ticagrelor was associated with a significantly lower risk of MACE (hazard ratio 0.79, 0.67 to 0.93, p <0.01) and hospitalization (hazard ratio 0.85, 0.77 to 0.95, p <0.01). No difference was observed in the risk of major bleeding. A statistically nonsignificant trend toward reduced risk of all-cause mortality was noted. In conclusion, in a real-world high-risk cohort, ticagrelor was associated with decreased risk of MACE and all-cause hospitalization compared with clopidogrel after PCI for ACS.
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Affiliation(s)
- Evan J Wiens
- Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Silvia J Leon
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; Section of Nephology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ashish H Shah
- Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada; Institute of Cardiovascular Sciences, Albretchsen Research Center, Winnipeg, Manitoba, Canada.
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Khandelwal G, Spirito A, Tanner R, Koshy AN, Sartori S, Salehi N, Giustino G, Dhulipala V, Zhang Z, Gonzalez J, Hooda A, Vinayak M, Shaikh A, Mehran R, Kini AS, Sharma SK. Validation of UK-BCIS CHIP Score to Predict 1-Year Outcomes in a Contemporary United States Population. JACC Cardiovasc Interv 2023; 16:1011-1020. [PMID: 37164597 DOI: 10.1016/j.jcin.2023.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/19/2023] [Accepted: 02/07/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND A complex high-risk indicated percutaneous coronary intervention (CHIP) score was recently developed from the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and their risk of in-hospital major adverse cardiac or cerebrovascular events (MACCE). OBJECTIVES The authors sought to apply this score to a contemporary U.S. population for the prediction of adverse events at 1 year following percutaneous coronary intervention (PCI). METHODS Consecutive patients undergoing PCI at a large tertiary care center between 2011 and 2020 were considered for inclusion. Patients were categorized into 4 groups based on their BCIS-CHIP score (0, 1-2, 3-4, ≥5). In each category, we assessed the 1-year risk of MACCE, a composite of all-cause death, myocardial infarction, and stroke. Secondary outcomes were the individual components of MACCE, and major bleeding at 1 year. RESULTS Among 20,799 patients included, MACCE at 1 year occurred in 1.7% patients with score 0 (reference), 3.0% with score 1 or 2 (HR: 1.72; 95% CI: 1.32-2.24), 6.1% with score 3 or 4 (HR: 3.60; 95% CI: 2.78-4.66), and 12.0% with score ≥5 (HR: 7.40; 95% CI: 5.75-9.51). Each point increase of the BCIS-CHIP score conferred a 28.0% increase of MACCE risk. The BCIS-CHIP score demonstrated good discrimination for the prediction of 1-year MACCE (C-index 0.70). The risk of secondary outcomes also progressively increased with higher score values. CONCLUSIONS In a large PCI registry, the BCIS-CHIP score had a good predictive value for MACCE at 1 year. The utilization of this score can facilitate an accurate risk stratification of patients undergoing PCI.
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Affiliation(s)
- Gaurav Khandelwal
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Tanner
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anoop N Koshy
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samantha Sartori
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Negar Salehi
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Giustino
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vishal Dhulipala
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhongjie Zhang
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jaime Gonzalez
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amit Hooda
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Manish Vinayak
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Asif Shaikh
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Annapoorna S Kini
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samin K Sharma
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Siasos G, Tsigkou V, Bletsa E, Stampouloglou PK, Oikonomou E, Kalogeras K, Katsarou O, Pesiridis T, Vavuranakis M, Tousoulis D. Antithrombotic Treatment in Coronary Artery Disease. Curr Pharm Des 2023; 29:2764-2779. [PMID: 37644793 DOI: 10.2174/1381612829666230830105750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/16/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023]
Abstract
Coronary artery disease exhibits growing mortality and morbidity worldwide despite the advances in pharmacotherapy and coronary intervention. Coronary artery disease is classified in the acute coronary syndromes and chronic coronary syndromes according to the most recent guidelines of the European Society of Cardiology. Antithrombotic treatment is the cornerstone of therapy in coronary artery disease due to the involvement of atherothrombosis in the pathophysiology of the disease. Administration of antiplatelet agents, anticoagulants and fibrinolytics reduce ischemic risk, which is amplified early post-acute coronary syndromes or post percutaneous coronary intervention; though, antithrombotic treatment increases the risk for bleeding. The balance between ischemic and bleeding risk is difficult to achieve and is affected by patient characteristics, procedural parameters, concomitant medications and pharmacologic characteristics of the antithrombotic agents. Several pharmacological strategies have been evaluated in patients with coronary artery disease, such as the effectiveness and safety of antithrombotic agents, optimal dual antiplatelet treatment schemes and duration, aspirin de-escalation strategies of dual antiplatelet regimens, dual inhibition pathway strategies as well as triple antithrombotic therapy. Future studies are needed in order to investigate the gaps in our knowledge, including special populations.
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Affiliation(s)
- Gerasimos Siasos
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
- Cardiovascular Division, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Vasiliki Tsigkou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evanthia Bletsa
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Panagiota K Stampouloglou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evangelos Oikonomou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Konstantinos Kalogeras
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Ourania Katsarou
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Theodoros Pesiridis
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Manolis Vavuranakis
- Department of Cardiology, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Dimitris Tousoulis
- Department of Cardiology, School of Medicine, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Wöhrle J, Seeger J. Prasugrel and Ticagrelor Treatment Among Patients With ACS: Is There a Need for a New Randomized Trial? JACC Cardiovasc Interv 2022; 15:2281-2283. [PMID: 36423971 DOI: 10.1016/j.jcin.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany.
| | - Julia Seeger
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
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