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Gurbel PA, Rout A, Tantry US. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Stolarek W, Kasprzak M, Sikora J, Siemińska E, Grześk G. High on-treatment platelet reactivity to aspirin in patients after myocardial infarction. Biomed Pharmacother 2022; 147:112618. [DOI: 10.1016/j.biopha.2022.112618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/22/2021] [Accepted: 01/02/2022] [Indexed: 11/27/2022] Open
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Metformin use in patients hospitalized with COVID-19: lower inflammation, oxidative stress, and thrombotic risk markers and better clinical outcomes. J Thromb Thrombolysis 2022; 53:363-371. [PMID: 35041121 PMCID: PMC8764325 DOI: 10.1007/s11239-022-02631-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 12/11/2022]
Abstract
Diabetes mellitus (DM) is associated with a greater risk of COVID-19 and an increased mortality when the disease is contracted. Metformin use in patients with DM is associated with less COVID-19-related mortality, but the underlying mechanism behind this association remains unclear. Our aim was to explore the effects of metformin on markers of inflammation, oxidative stress, and hypercoagulability, and on clinical outcomes. Patients with DM on metformin (n = 34) and metformin naïve (n = 41), and patients without DM (n = 73) were enrolled within 48 h of hospital admission for COVID-19. Patients on metformin compared to naïve patients had a lower white blood cell count (p = 0.02), d-dimer (p = 0.04), urinary 11-dehydro thromboxane B2 (p = 0.01) and urinary liver-type fatty acid binding protein (p = 0.03) levels and had lower sequential organ failure assessment score (p = 0.002), and intubation rate (p = 0.03), fewer hospitalized days (p = 0.13), lower in-hospital mortality (p = 0.12) and lower mortality plus nonfatal thrombotic event occurrences (p = 0.10). Patients on metformin had similar clinical outcomes compared to patients without DM. In a multiple regression analysis, metformin use was associated with less days in hospital and lower intubation rate. In conclusion, metformin treatment in COVID-19 patients with DM was associated with lower markers of inflammation, renal ischemia, and thrombosis, and fewer hospitalized days and intubation requirement. Further focused studies are required to support these findings.
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Tantry US, Schror K, Navarese EP, Jeong YH, Kubica J, Bliden KP, Gurbel PA. Aspirin as an Adjunctive Pharmacologic Therapy Option for COVID-19: Anti-Inflammatory, Antithrombotic, and Antiviral Effects All in One Agent. J Exp Pharmacol 2021; 13:957-970. [PMID: 34908882 PMCID: PMC8665864 DOI: 10.2147/jep.s330776] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/22/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction Pharmacologic therapy options for COVID-19 should include antiviral, anti-inflammatory, and anticoagulant agents. With the limited effectiveness, currently available virus-directed therapies may have a substantial impact on global health due to continued reports of mutant variants affecting repeated waves of COVID-19 around the world. Methods We searched articles pertaining to aspirin, COVID-19, acute lung injury and pharmacology in PubMed and provide a comprehensive appraisal of potential use of aspirin in the management of patients with COVID-19. The scope of this article is to provide an overview of the rationale and currently available clinical evidence that supports aspirin as an effective therapeutic option in COVID-19. Results Experimental and clinical evidence are available for the potential use of aspirin in patients with COVID-19. Discussion Aspirin targets the intracellular signaling pathway that is essential for viral replication, and resultant inflammatory responses, hypercoagulability, and platelet activation. With these multiple benefits, aspirin can be a credible adjunctive therapeutic option for the treatment of COVID-19. In addition, inhaled formulation with its rapid effects may enhance direct delivery to the lung, which is the key organ damaged in COVID-19 during the critical initial course of the disease, whereas the 150-325 mg/day can be used for long-term treatment to prevent thrombotic event occurrences. Being economical and widely available, aspirin can be exploited globally, particularly in underserved communities and remote areas of the world to combat the ongoing COVID-19 pandemic.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, MD, USA
| | - Karsten Schror
- Department of Pharmacology and Clinical Pharmacology, Heinrich-Heine-University, Düsseldorf, Germany
| | - Eliano Pio Navarese
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, MD, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, LifeBridge Health, Baltimore, MD, USA
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Tantry US, Bliden KP, Cho A, Walia N, Dahlen JR, Ens G, Traianova M, Jerjian C, Usman A, Gurbel PA. First Experience Addressing the Prognostic Utility of Novel Urinary Biomarkers in Patients With COVID-19. Open Forum Infect Dis 2021; 8:ofab274. [PMID: 34250193 PMCID: PMC8194603 DOI: 10.1093/ofid/ofab274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/24/2021] [Indexed: 12/02/2022] Open
Abstract
Urine 11-dehydro-thromboxane B2 (u11-dh-TxB2), 8-hydroxy-2’-deoxyguanosine (8-OHdG), and liver-type fatty acid binding protein levels (L-FABP) at the time of hospitalization were higher in coronavirus disease 2019 (COVID-19) patients with adverse events vs without events. Higher u11-dh-TxB2 and L-FABP levels were associated with longer hospitalization, more thrombotic events, and greater mortality, providing evidence for potential utility as early prognostic biomarkers for COVID-19.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
| | - Alastair Cho
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
| | - Naval Walia
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
| | | | - Gordon Ens
- Inflammatory Markers Laboratory, Wichita, Kansas, USA
| | | | - Christophe Jerjian
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
| | - Abira Usman
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, Maryland, USA
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Gurbel PA, Bliden KP, Tantry US. Defining platelet response to acetylsalicylic acid: the relation between inhibition of serum thromboxane B 2 and agonist-induced platelet aggregation. J Thromb Thrombolysis 2020; 51:260-264. [PMID: 33170486 DOI: 10.1007/s11239-020-02334-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 11/24/2022]
Abstract
Arachidonic acid (AA)-induced platelet aggregation (PA) and serum thromboxane B2 (TxB2) inhibition are widely used to indicate cyclooxygenase-1 activity and the antiplatelet effect of acetylsalicylic acid (ASA). Despite decades of investigations, the relation between these measurements remains unclear. We sought to evaluate the relation between AA-PA and serum TxB2 inhibition. We serially measured AA-PA (conventional aggregation), serum TxB2, plasma ASA and salicylic acid (SA) (liquid chromatography-mass spectrometry), and urinary 11-dehydro thromboxane B2 (u11-dh TxB2) (enzyme-linked immunosorbent assay) levels at 10 times over 24 hours in seventeen healthy volunteers receiving a single dose of 162 mg chewed and swallowed ASA (n = 6), 50 mg inhaled ASA (n = 6), or 100 mg inhaled ASA (n = 5) (ClinicalTrials.gov Identifier: NCT04328883, April 1, 2020). Baseline variability was more pronounced with serum TxB2 (31-680 ng/mL) as compared to maximal AA-PA (65-81%) and u11-dh TxB2 (1556-4440 pg/mg creatinine). The relation between serum TxB2 inhibition and AA-PA was stepwise; after 30-40% inhibition of serum TxB2, AA-PA fell to < 5%. By receiver operating characteristic curve analysis using AA-PA < 5% to define aspirin responsiveness, serum TxB2 inhibition > 49% and u11-dh TxB2 < 1520 pg/mg creatinine met the definition. Our study demonstrates a non-linear relation between serum TxB2 inhibition and AA-PA. Aggregation was nil once TxB2 inhibition reached > 49%. Moreover, these results suggest that the definition of > 95% inhibition of serum TxB2 to indicate the level of platelet COX-1 inhibition needed for clinical efficacy may be overestimated and should be re-considered in future translational research investigations that attempt to link the clinical efficacy of ASA with a laboratory measurement cutoff.
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Affiliation(s)
- Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA.
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21215, USA
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Tantry U, Cummings C, Mackrell P, Gonze M, Ulloa K, Bafford R, Rout A, Sukhi A, Gurbel P. Synergistic influence of rivaroxaban on inflammation and coagulation biomarkers in patients with coronary artery disease and peripheral artery disease on aspirin therapy. Future Cardiol 2020; 16:69-75. [PMID: 32129681 DOI: 10.2217/fca-2019-0091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
COMPASS study demonstrated efficacy of dual pathway inhibition with 2.5 mg twice daily rivaroxaban and aspirin in patients with polyvascular disease (coronary artery disease, peripheral arterial disease or both), the underlying mechanism of which is not clearly understood. In this Phase IV, prospective, open-label and randomized study, we hypothesize that treatment with rivaroxaban is associated with a reduction in platelet activation and aggregation, inflammation and coagulation markers. 30 patients will be randomly treated with aspirin (81 mg q.d.) or aspirin plus rivaroxaban (2.5 mg b.i.d.) for 12 weeks. Platelet aggregation, platelet activation and inflammation markers, thrombin generation kinetics and tissue factor-induced platelet-fibrin clot strength will be measured at baseline, and 4 and 12 weeks after randomization. Trial registration number: NCT04059679.
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Affiliation(s)
- Udaya Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Charles Cummings
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Peter Mackrell
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Mark Gonze
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Kristian Ulloa
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Richard Bafford
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Amit Rout
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Ajaypaul Sukhi
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
| | - Paul Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA
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Tantry US, Timilsina S, Rout A, Bliden K, Gurbel PA. Assessing platelet reactivity after drug eluting stent implantation: state of the art. Expert Rev Cardiovasc Ther 2020; 18:17-24. [PMID: 32003297 DOI: 10.1080/14779072.2020.1724536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Platelets play a pivotal role in the occurrence of recurrent ischemic events in coronary artery disease patients who are treated with drug-eluting stents and are on dual antiplatelet therapy (DAPT).Areas covered: High platelet reactivity (HPR) to adenosine diphosphate during clopidogrel therapy is a strong predictor of post-stenting ischemic event occurrences. However, uniform use of potent P2Y12 receptors blockers to overcome HPR is associated with elevated bleeding risk. Selective de-escalation of P2Y12 receptor blocker therapy based on PFT in patients with acute coronary syndrome treated with stenting has been shown to be associated with a similar risk of ischemic event occurrence but with a reduced risk of bleeding. This review aims to discuss the role of PFT in guiding DAPT in patients treated with DES. We searched electronic databases from January 2000 to December 2019 for literatures evaluating the role of platelet function assessment after drug eluting stents.Expert opinion: Platelet function guided therapy improves patient outcomes by lessening bleeding and limiting the overuse of highly potent P2Y12 inhibitors. Interest in this area of de-escalation of therapy will likely grow as the consequences of bleeding are better recognized and the cost of healthcare gains greater focus.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Saroj Timilsina
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Amit Rout
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Kevin Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Gurbel PA, Navarese EP, Tantry US. The optimal antithrombotic regimen to prevent post-CABG adverse events: an ongoing controversy. Eur Heart J 2019; 40:2441-2443. [DOI: 10.1093/eurheartj/ehz263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Mater Dei Hospital, Bari, BA, Italy
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Gurbel P, Tantry U, Weisman S. A narrative review of the cardiovascular risks associated with concomitant aspirin and NSAID use. J Thromb Thrombolysis 2018; 47:16-30. [DOI: 10.1007/s11239-018-1764-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Stroke is a leading cause of death and disability worldwide. Aspirin is the most commonly used antiplatelet drug in both primary and secondary prevention of cerebrovascular and cardiovascular diseases. A proportion of patients may have stroke recurrence while they are on treatment with aspirin, giving rise to term aspirin resistance or aspirin failure. Studies have suggested that such recurrence could partly be attributed to biochemical aspirin resistance, with an estimated prevalence ranging between 5% and 65% among patients with ischemic stroke in the published studies. Common methods to evaluate laboratory aspirin resistance include light transmission aggregometry, PFA-100, VerifyNow-Aspirin assay, serum thromboxane B2, and urinary 11-dehydrothromboxane B2. Aspirin resistance is multifactorial in origin and involves diverse environmental and genetic factors, including single-nucleotide polymorphisms, miRNAs, drug interactions, and co-morbid risk factors. The current review overviews the concept of aspirin resistance, its evaluation and relationship with stroke recurrence, its outcome, and its implications on stroke management in the future.
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Affiliation(s)
- Pranjal Sisodia
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
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Florin L, Devreese KMJ. Evaluation of AggreGuide A-100 for monitoring of antiplatelet therapy. Int J Lab Hematol 2018; 40:e113-e116. [DOI: 10.1111/ijlh.12872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- L. Florin
- Coagulation Laboratory; Department of Laboratory Medicine; Ghent University Hospital; Ghent Belgium
| | - K. M. J. Devreese
- Coagulation Laboratory; Department of Laboratory Medicine; Ghent University Hospital; Ghent Belgium
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Tantry US, Navarese EP, Myat A, Chaudhary R, Gurbel PA. Combination oral antithrombotic therapy for the treatment of myocardial infarction: recent developments. Expert Opin Pharmacother 2018; 19:653-665. [DOI: 10.1080/14656566.2018.1457649] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Eliano P. Navarese
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Aung Myat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust and Faculty of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - Rahul Chaudhary
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
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Thomas K, Moody TW, Jensen RT, Tong J, Rayner CL, Barnett NL, Fairfull-Smith KE, Ridnour LA, Wink DA, Bottle SE. Design, synthesis and biological evaluation of hybrid nitroxide-based non-steroidal anti-inflammatory drugs. Eur J Med Chem 2018; 147:34-47. [PMID: 29421569 PMCID: PMC8202972 DOI: 10.1016/j.ejmech.2018.01.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/15/2018] [Accepted: 01/23/2018] [Indexed: 11/23/2022]
Abstract
Dual-acting hybrid anti-oxidant/anti-inflammatory agents were developed employing the principle of pharmacophore hybridization. Hybrid agents were synthesized by combining stable anti-oxidant nitroxides with conventional non-steroidal anti-inflammatory drugs (NSAIDs). Several of the hybrid nitroxide-NSAID conjugates displayed promising anti-oxidant and anti-inflammatory effects on two Non-Small Cell Lung Cancer (NSCLC) cells (A549 and NCI-H1299) and in ameliorating oxidative stress induced in 661 W retinal cells. One ester-linked nitroxide-aspirin analogue (27) delivered better anti-inflammatory effects (cyclooxygenase inhibition) than the parent compound (aspirin), and also showed similar reactive oxygen scavenging activity to the anti-oxidant, Tempol. In addition, a nitroxide linked to the anti-inflammatory drug indomethacin (39) significantly ameliorated the effects of oxidative stress on 661 W retinal neurons at efficacies greater or equal to the anti-oxidant Lutein. Other examples of the hybrid conjugates displayed promising anti-cancer activity, as demonstrated by their inhibitory effects on the proliferation of A549 NSCLC cells.
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Affiliation(s)
- Komba Thomas
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, (QUT) GPO Box 2434, Brisbane, QLD 4001, Australia
| | - Terry W Moody
- Center for Cancer Research, National Cancer Institute, Cancer and Inflammation Program, Frederick, MD 21702-1201, USA
| | - Robert T Jensen
- Center for Cancer Research, National Cancer Institute, Cancer and Inflammation Program, Frederick, MD 21702-1201, USA
| | - Jason Tong
- Queensland Eye Institute, South Brisbane, Queensland, Australia
| | - Cassie L Rayner
- Queensland Eye Institute, South Brisbane, Queensland, Australia
| | - Nigel L Barnett
- Queensland Eye Institute, South Brisbane, Queensland, Australia; The University of Queensland, UQ Centre for Clinical Research, Herston, Queensland, Australia
| | - Kathryn E Fairfull-Smith
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, (QUT) GPO Box 2434, Brisbane, QLD 4001, Australia
| | - Lisa A Ridnour
- Center for Cancer Research, National Cancer Institute, Cancer and Inflammation Program, Frederick, MD 21702-1201, USA
| | - David A Wink
- Center for Cancer Research, National Cancer Institute, Cancer and Inflammation Program, Frederick, MD 21702-1201, USA
| | - Steven E Bottle
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, (QUT) GPO Box 2434, Brisbane, QLD 4001, Australia.
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Pepine CJ, Gurbel PA. Cardiovascular safety of NSAIDs: Additional insights after PRECISION and point of view. Clin Cardiol 2017; 40:1352-1356. [PMID: 29247518 DOI: 10.1002/clc.22814] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/06/2017] [Accepted: 09/08/2017] [Indexed: 01/12/2023] Open
Abstract
Increasing numbers of patients with arthritis use nonsteroidal anti-inflammatory drugs (NSAIDs), some for long periods. The relative cardiovascular safety of NSAID use is of considerable concern, particularly among patients with or at risk of cardiovascular disease. Until recently, the evidence base was limited to older trials with small sample sizes. The large-scale Prospective Randomized Evaluation of Celecoxib Integrated Safety vs Ibuprofen or Naproxen (PRECISION) trial and a recent Bayesian meta-analysis of individual patient data in nearly a half-million patients were undertaken to address some of the existing gaps in knowledge relative to the cardiovascular safety of NSAID use. We reviewed the results, strengths, and limitations of PRECISION. We believe that the results of the meta-analysis will further assist clinicians in decision-making for management of patients with osteoarthritis. The totality of evidence would support avoidance of NSAID use, if possible, in patients with or at high risk for cardiovascular disease. If used, the shortest-duration and lowest effective NSAID doses should be chosen, given the evidence that risk is duration- and dose-dependent. We also provide a brief discussion of the mechanism of action of NSAIDs, along with discussion of existing guidelines and the recent meta-analysis.
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Affiliation(s)
- Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, Virginia
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Bliden KP, Singla A, Gesheff MG, Toth PP, Tabrizchi A, Ens G, Guyer K, Singh M, Franzese CJ, Stapleton DD, Tantry US, Gurbel PA. Statin therapy and thromboxane generation in patients with coronary artery disease treated with high-dose aspirin. Thromb Haemost 2017; 112:323-31. [DOI: 10.1160/th14-01-0094] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/03/2014] [Indexed: 11/05/2022]
Abstract
SummaryAspirin and statin therapy are mainstay treatments in patients with coronary artery disease (CAD). The relation between statin therapy, in vivo thromboxane (Tx) generation; a marker of inflammation, and blood thrombogenicity has never been explored. Urinary 11-dehydro (dh) TxB2 was determined in patients with suspected CAD on 325 mg daily aspirin therapy prior to undergoing cardiac catheterisation (n=281). Thrombogenicity was estimated by thrombelastographic measurement of thrombin-induced platelet-fibrin clot strength (TIP-FCS) and lipids/lipoproteins were determined by vertical density gradient ultracentrifugation/ELISA. The influence of statin therapy and dose was analysed by the atorvastatin equivalent dose (5–10 mg, 20–40 mg, or 80 mg daily). Statin therapy (n=186) was associated with a dose-dependent reduction in urinary 11-dh TxB2 (p=0.046) that was independent of LDL and apo B100 levels but was strongly related to TIP-FCS (p=0.006). By multivariate analysis, no statin therapy (n=95) and female gender were independently associated with high urinary 11-dh TxB2 [OR=2.95 (0.1.57–5.50, p=0.0007); OR=2.25 (1.24–4.05, p=0.007)], respectively. In aspirin-treated patients, statin therapy was independently and inversely associated with inflammation in a dose-dependent manner. Elevated 11-dh TxB2 was associated with a prothrombotic state indicated by high TIP-FCS. Our data suggest that measurement of urinary 11-dTxB2 may be a useful method to optimise statin dosing in order to reduce thrombotic risk.
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Exploration of PCSK9 as a Cardiovascular Risk Factor. J Am Coll Cardiol 2017; 70:1463-1466. [DOI: 10.1016/j.jacc.2017.07.779] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 11/24/2022]
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Al-Jabi SW. Global Trends in Aspirin Resistance-Related Research from 1990 to 2015: A Bibliometric Analysis. Basic Clin Pharmacol Toxicol 2017; 121:512-519. [PMID: 28667787 DOI: 10.1111/bcpt.12840] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/27/2017] [Indexed: 12/14/2022]
Abstract
Aspirin resistance can be defined as the inability of the usual dose of aspirin medication to produce its antithrombotic effect. Patients with diabetes or cardiovascular disease are at higher risk of stroke, myocardial infarction or cardiovascular death due to aspirin resistance. The aim of this bibliometric study was to identify and analyse the status and trends of aspirin resistance research production at global level through publications indexed in the Scopus database; this will shed new light on future research trends and help researchers predict dynamic direction of research. Literature search using the Scopus database was conducted to assess publications related to aspirin resistance. The selected publications included the terms related to aspirin resistance in the title, abstract or keywords. The searching was accomplished on 20 March 2016 and can be considered to include all publications up to 31 December 2015. Global cumulative publication output on aspirin resistance consists of 986 papers during 1990-2015. Among the 986 documents, 19 (1.9%) were published before 2000, 567 (57.5%) were published from 2000 to 2009 and 400 (40.6%) were published from 2010 to 2015, with peak of publications on this topic in 2008. The leading country in the field of aspirin resistance was the United States, which had the greatest counts of independent articles (165) and international collaboration articles (44). Turkey was in the second rank with 78 articles, followed by Italy (68), the UK (62) and Poland (60). The total number of citations for all documents was 26,342, and the average citations per document were 26.7. The h-index for all aspirin resistance publications was 82. This study presents the results of the first bibliometric study (including quantitative and qualitative analysis) of scientific publications in the field of aspirin renitence at global level. Aspirin resistance-related researches have notably increased in the last years, especially from 2000 to 2015. The United States is the most prolific country, not only in research quantity but also in quality. Furthermore, Turkey and European countries provided more research related to aspirin resistance than other regions such as the developing countries.
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Affiliation(s)
- Samah W Al-Jabi
- Department of Clinical and Community Pharmacy, Faulty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Gurbel PA, Tantry US. GEMINI-ACS-1: toward unearthing the antithrombotic therapy cornerstone for acute coronary syndromes. Lancet 2017; 389:1773-1775. [PMID: 28325639 DOI: 10.1016/s0140-6736(17)30760-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA 22042, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA; Duke University School of Medicine, Durham, NC, USA.
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA 22042, USA
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Sharma T, Bliden K, Chaudhary R, Tantry U, Gurbel PA. Efficacy of aspirin (325 mg) + omeprazole (40 mg) in treating coronary artery disease. Expert Opin Pharmacother 2016; 18:123-131. [DOI: 10.1080/14656566.2016.1269747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Tushar Sharma
- Department of Medicine, Sinai Hospital, Baltimore, MD, USA
| | - Kevin Bliden
- Director of Cardiovascular Research, Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | | | - Udaya Tantry
- Director of Cardiovascular Research, Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
| | - Paul A. Gurbel
- Director of Cardiovascular Research, Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA, USA
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Olechowski B, Ashby A, Mariathas M, Khanna V, Mahmoudi M, Curzen N. Is arachidonic acid stimulation really a test for the response to aspirin? Time to think again? Expert Rev Cardiovasc Ther 2016; 15:35-46. [DOI: 10.1080/14779072.2017.1266255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Bartosz Olechowski
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Ashby
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Mariathas
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vikram Khanna
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Myat A, Tantry US, Kubica J, Gurbel PA. Current controversies in the use of aspirin and ticagrelor for the treatment of thrombotic events. Expert Rev Cardiovasc Ther 2016; 14:1361-1370. [PMID: 27740874 DOI: 10.1080/14779072.2016.1247693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A P2Y12 inhibitor plus aspirin is the most widely used antiplatelet strategy to prevent adverse outcomes in the setting of atherothrombotic vascular disease. Areas covered: A paucity of robust evidence for an optimal dose, gastrointestinal toxicity, ineffectiveness in high-risk patients and interactions with other antiplatelet agents, are major controversies associated with aspirin therapy. Ticagrelor is a reversibly binding oral P2Y12 receptor blocker that mediates potent inhibition of adenosine diphosphate-induced platelet function. It is more effective than clopidogrel in preventing thrombotic events in acute coronary syndrome patients. The absence of a beneficial effect for ticagrelor versus clopidogrel in ACS observed in the North American subgroup of the PLATelet inhibition and patient Outcomes (PLATO) trial has been attributed to a higher concomitant aspirin dose. Expert commentary: Ongoing studies are now investigating the plausibility of removing aspirin therapy in the setting of potent P2Y12 receptor blockade via ticagrelor monotherapy or replacing aspirin with an oral anticoagulant.
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Affiliation(s)
- Aung Myat
- a Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust and Faculty of Medicine , Brighton and Sussex Medical School , Brighton , UK
| | - Udaya S Tantry
- b Inova Center for Thrombosis Research and Drug Development , Inova Heart and Vascular Institute , Falls Church , VA , USA
| | - Jacek Kubica
- c Department of Cardiology, and Internal Medicine, Ludwik Rydygier Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Paul A Gurbel
- b Inova Center for Thrombosis Research and Drug Development , Inova Heart and Vascular Institute , Falls Church , VA , USA
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High prevalence of aspirin resistance in elderly patients with cardiovascular disease and metabolic syndrome. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:531-6. [PMID: 27582771 PMCID: PMC4987425 DOI: 10.11909/j.issn.1671-5411.2016.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Metabolic syndrome is known to be a prothrombotic state. We undertook this study to examine a hypothesis that aspirin resistance may be associated with metabolic syndrome, and to assess other potential determinants of aspirin resistance in patients with cardiovascular disease (CVD). Methods A total of 469 elderly patients with CVD were recruited. One hundred and seventy-two patients with metabolic syndrome and 297 without metabolic syndrome (control group) received daily aspirin therapy (≥ 75 mg) over one month. Platelet aggregation was measured by light transmission aggregometry (LTA). Aspirin resistance was defined as ≥ 20% arachidonic acid (AA)- and ≥ 70% adenosine diphosphate (ADP)-induced aggregation according to LTA. Aspirin semi-responders were defined as meeting one (but not both) of these criteria. Results By LTA, 38 of 469 (8.1%) patients were aspirin resistant. The prevalence of aspirin resistance was higher in the metabolic syndrome group compared with the control group [11.6 % vs. 6.6%, odds ratio (OR) = 2.039; 95% confidence interval (CI): 1.047–3.973]. In the multivariate logistic regression analysis, metabolic syndrome (OR = 4.951, 95% CI: 1.440–17.019, P = 0.011) was a significant risk factor for aspirin resistance. Conclusions A significant number of patients with CVD and metabolic syndrome are resistant to aspirin therapy. This might further increase the risk of cardiovascular morbidity and mortality in these patients.
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Mahla E, Tantry US, Gurbel PA. To stop or continue aspirin before aortocoronary bypass operations-do we have enough evidence to adequately guide us? J Thorac Dis 2016; 8:E578-80. [PMID: 27501008 DOI: 10.21037/jtd.2016.05.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, USA
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Bliden KP, Tantry US, Chaudhary R, Byun S, Gurbel PA. Extended-release acetylsalicylic acid for secondary prevention of stroke and cardiovascular events. Expert Rev Cardiovasc Ther 2016; 14:779-91. [DOI: 10.1080/14779072.2016.1188005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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The monitoring of antiaggregation effect of acetylsalicylic acid therapy by measuring serum thromboxane B2 in patients with coronary artery bypass grafting. Blood Coagul Fibrinolysis 2016; 27:370-3. [PMID: 26575493 DOI: 10.1097/mbc.0000000000000438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gurbel PA, Jeong YH, Navarese EP, Tantry US. Platelet-Mediated Thrombosis. Circ Res 2016; 118:1380-91. [DOI: 10.1161/circresaha.115.307016] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 02/17/2016] [Indexed: 11/16/2022]
Abstract
The pivotal role that platelets play in thrombosis and resultant ischemic event occurrences in patients with high-risk coronary artery disease is well established. This role provides the fundamental basis for the current wide implementation of dual antiplatelet therapy with aspirin and a P2Y
12
receptor inhibitor. The development of user friendly point-of-care methods to assess platelet reactivity to adenosine diphosphate has increased the frequency of platelet function testing in clinical practice. Recent large observational studies have established an independent relation between the results of point-of-care platelet function testing and clinical event occurrence in patients undergoing coronary artery stenting. However, prospective, randomized trials have failed to demonstrate that personalized antiplatelet therapy based on point-of-care assessment of platelet function is effective in reducing ischemic event occurrences. Important limitations were associated with these trials. In addition, the concept of a therapeutic window of P2Y
12
receptor reactivity with an upper threshold associated with ischemic event occurrence and a lower threshold associated with bleeding has also been proposed. In the absence of strong prospective evidence to support personalized antiplatelet therapy, clinical decision making about antiplatelet therapy rests on the large body of observational data and the fundamental importance of platelet physiology in catastrophic event occurrence in patients with high-risk coronary artery disease.
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Affiliation(s)
- Paul A. Gurbel
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
| | - Young-Hoon Jeong
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
| | - Eliano P. Navarese
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
| | - Udaya S. Tantry
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
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Gurbel PA, Tantry US. Antithrombotic therapy in medically managed patients with non-ST-segment elevation acute coronary syndromes. Heart 2016; 102:882-92. [DOI: 10.1136/heartjnl-2014-306695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gurbel PA, Myat A, Kubica J, Tantry US. State of the art: Oral antiplatelet therapy. JRSM Cardiovasc Dis 2016; 5:2048004016652514. [PMID: 27298725 PMCID: PMC4892624 DOI: 10.1177/2048004016652514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/05/2016] [Indexed: 11/17/2022] Open
Abstract
Platelet adhesion, activation, and aggregation are central to the propagation of coronary thrombosis following rupture, fissure, or erosion of an atherosclerotic plaque. This chain of deleterious events underlies the pathophysiological process leading to an acute coronary syndrome. Therefore, oral antiplatelet therapy has become the cornerstone of therapy for the management of acute coronary syndrome and the prevention of ischemic complications associated with percutaneous coronary intervention. Landmark trials have established aspirin, and the addition of clopidogrel to aspirin, as key therapeutic agents in the context of acute coronary syndrome and percutaneous coronary intervention. Dual antiplatelet therapy has been the guideline-mandated standard of care in acute coronary syndrome and percutaneous coronary intervention. Despite the proven efficacy of dual antiplatelet therapy, adverse ischemic events continue to occur and this has stimulated the development of novel, more potent antiplatelet agents. We focus this state-of-the-art review on the most recent advances in oral antiplatelet therapy, treading the tightrope of potency versus bleeding risk, the quest to determine the optimal duration of dual antiplatelet therapy and future of personalized antiplatelet therapy.
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Affiliation(s)
- Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Aung Myat
- Cardiology Department, University Hospital Coventry, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Jacek Kubica
- Department of Cardiology, and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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Abstract
Diabetes imparts a substantial increased risk for cardiovascular disease-related mortality and morbidity. Because of this, current medical guidelines recommend prophylactic treatment with once-daily, low-dose aspirin (acetylsalicylic acid) for primary and secondary prevention of cardiovascular (CV) events in high-risk patients. However, only modest reductions in CV events and mortality have been observed with once-daily aspirin treatment in patients with diabetes, including patients with a previous CV event, perhaps because of disparity between aspirin pharmacokinetics and diabetes-related platelet abnormalities. Once-daily aspirin irreversibly inactivates platelets for only a short duration (acetylsalicylic acid half-life, approximately 15-20 minutes), after which time newly generated, active platelets enter the circulation and weaken aspirin's effect. Platelets from patients with diabetes are more reactive and are turned over more rapidly than platelets from normal individuals; the short inhibitory window provided by once-daily aspirin may therefore be insufficient to provide 24-h protection against CV events. Alternative conventional aspirin regimens (e.g. higher daily dose, twice-daily dosing, combination with clopidogrel) and newer formulations (e.g. 24-h, extended-release) have been proposed to overcome the apparent limited efficacy of conventional aspirin in patients with diabetes; however, tolerability concerns and limited clinical efficacy data need to be taken into account when considering the use of such regimens.
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Oliphant CS, Trevarrow BJ, Dobesh PP. Clopidogrel Response Variability: Review of the Literature and Practical Considerations. J Pharm Pract 2015; 29:26-34. [PMID: 26589471 DOI: 10.1177/0897190015615900] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is standard therapy following acute coronary syndrome and percutaneous coronary intervention. Despite the use of potent antiplatelet agents, vascular events continue to occur. Lack of response to clopidogrel therapy has been widely investigated using various methods of platelet function testing. These studies have consistently found an association between poor clopidogrel response and an increased risk of vascular events. Strategies to overcome this problem include higher clopidogrel doses or the use of an alternative P2Y12 agent. To date, the majority of studies investigating tailored antiplatelet therapy have failed to show any reduction in clinical events likely due to the low-risk population studied. Despite this lack of benefit from altering therapy, platelet function testing may be done in certain patient populations. Patients at high risk of deleterious outcomes from stent thrombosis may be an appropriate patient population for platelet function testing to ensure adequate response to therapy. In addition, emerging data suggests a potential role for platelet function testing to assess for bleeding risk. The purpose of this article is to review the key studies demonstrating response variability to clopidogrel therapy, strategies to overcome variability, and practical considerations for the clinician.
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Affiliation(s)
- Carrie S Oliphant
- Methodist Healthcare, University Hospital, Memphis, TN, USA Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, TN, USA
| | - Brian J Trevarrow
- Department of Pharmaceutical and Nutrition Care-Nebraska Medicine, Omaha, NE, USA College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
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Bliden KP, Patrick J, Pennell AT, Tantry US, Gurbel PA. Drug delivery and therapeutic impact of extended-release acetylsalicylic acid. Future Cardiol 2015; 12:45-58. [PMID: 26356085 DOI: 10.2217/fca.15.60] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Current treatment guidelines recommend once-daily, low-dose acetylsalicylic acid (ASA; aspirin) for secondary prevention of cardiovascular events. However, the anti-thrombotic benefits of traditional ASA formulations may not extend over a 24-h period, especially in patients at high risk for a recurrent cardiovascular event. A next-generation, extended-release ASA formulation (ER-ASA) has been developed to provide 24-h anti-thrombotic coverage with once-daily dosing. The pharmacokinetics of ER-ASA indicates slower absorption and prolonged ASA release versus immediate-release ASA, with a favorable safety profile. ER-ASA minimizes systemic ASA absorption and provides sustained antiplatelet effects over a 24-h period.
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Affiliation(s)
- Kevin P Bliden
- Sinai Center for Thrombosis Research, Baltimore, MD, USA
| | - Jeff Patrick
- New Haven Pharmaceuticals, Inc., North Haven, CT, USA
| | | | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Baltimore, MD, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Baltimore, MD, USA
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Yang Y, Lewis JP, Hulot JS, Scott SA. The pharmacogenetic control of antiplatelet response: candidate genes and CYP2C19. Expert Opin Drug Metab Toxicol 2015; 11:1599-617. [PMID: 26173871 DOI: 10.1517/17425255.2015.1068757] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Aspirin, clopidogrel, prasugrel and ticagrelor are antiplatelet agents for the prevention of ischemic events in patients with acute coronary syndromes (ACS), percutaneous coronary intervention (PCI) and other indications. Variability in response is observed to different degrees with these agents, which can translate to increased risks for adverse cardiovascular events. As such, potential pharmacogenetic determinants of antiplatelet pharmacokinetics, pharmacodynamics and clinical outcomes have been actively studied. AREAS COVERED This article provides an overview of the available antiplatelet pharmacogenetics literature. Evidence supporting the significance of candidate genes and their potential influence on antiplatelet response and clinical outcomes are summarized and evaluated. Additional focus is directed at CYP2C19 and clopidogrel response, including the availability of clinical testing and genotype-directed antiplatelet therapy. EXPERT OPINION The reported aspirin response candidate genes have not been adequately replicated and few candidate genes have thus far been implicated in prasugrel or ticagrelor response. However, abundant data support the clinical validity of CYP2C19 and clopidogrel response variability among ACS/PCI patients. Although limited prospective trial data are available to support the utility of routine CYP2C19 testing, the increased risks for reduced clopidogrel efficacy among ACS/PCI patients that carry CYP2C19 loss-of-function alleles should be considered when genotype results are available.
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Affiliation(s)
- Yao Yang
- a 1 Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences , New York, NY, USA +1 212 241 3780 ; +1 212 241 0139 ;
| | - Joshua P Lewis
- b 2 University of Maryland School of Medicine, Division of Endocrinology, Diabetes and Nutrition, and Program for Personalized and Genomic Medicine , Baltimore, MD, USA
| | - Jean-Sébastien Hulot
- c 3 Icahn School of Medicine at Mount Sinai, Cardiovascular Research Center , New York, NY, USA.,d 4 Sorbonne Universités, UPMC Univ Paris 06, INSERM , UMR_S 1166 ICAN, F-75005 Paris, France
| | - Stuart A Scott
- a 1 Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences , New York, NY, USA +1 212 241 3780 ; +1 212 241 0139 ;
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Franzese CJ, Bliden KP, Gesheff MG, Pandya S, Guyer KE, Singla A, Tantry US, Toth PP, Gurbel PA. Relation of fish oil supplementation to markers of atherothrombotic risk in patients with cardiovascular disease not receiving lipid-lowering therapy. Am J Cardiol 2015; 115:1204-11. [PMID: 25759102 DOI: 10.1016/j.amjcard.2015.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 12/15/2022]
Abstract
Fish oil supplementation (FOS) is known to have cardiovascular benefits. However, the effects of FOS on thrombosis are incompletely understood. We sought to determine if the use of FOS is associated with lower indices of atherothrombotic risk in patients with suspected coronary artery disease (sCAD). This is a subgroup analysis of consecutive patients with sCAD (n=600) enrolled in the Multi-Analyte, Thrombogenic, and Genetic Markers of Atherosclerosis study. Patients on FOS were compared with patients not on FOS. Lipid profile was determined by vertical density gradient ultracentrifugation (n=520), eicosapentaenoic acid+docosahexaenoic acid was measured by gas chromatography (n=437), and AtherOx testing was performed by immunoassay (n=343). Thromboelastography (n=419), ADP- and collagen-induced platelet aggregation (n=137), and urinary 11-dehydrothromboxane B2 levels (n=259) were performed immediately before elective coronary angiography. In the total population, FOS was associated with higher eicosapentaenoic acid+docosahexaenoic acid content (p<0.001), lower triglycerides (p=0.04), total very low-density lipoprotein cholesterol (p=0.002), intermediate-density lipoprotein cholesterol (p=0.02), and AtherOx levels (p=0.02) but not in patients on lipid-lowering therapy. Patients not on lipid-lowering therapy taking FOS had lower very low-density lipoprotein cholesterol, intermediate-density lipoprotein cholesterol, remnant lipoproteins, triglycerides, low-density lipoprotein cholesterol, AtherOx levels, collagen-induced platelet aggregation, thrombin-induced platelet-fibrin clot strength, and shear elasticity (p<0.03 for all). In clopidogrel-treated patients, there was no difference in ADP-induced aggregation between FOS groups. Patients on FOS had lower urinary 11-dehydrothromboxane B2 levels regardless of lipid-lowering therapy (p<0.04). In conclusion, the findings of this study support the potential benefit of FOS for atherothrombotic risk reduction in sCAD with the greatest benefit in patients not receiving lipid-lowering therapy. Future prospective studies to compare FOS with lipid-lowering therapy and to assess the independent effects of FOS on thrombogenicity are needed.
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Affiliation(s)
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research, Sinai Hospital, Baltimore, Maryland
| | - Martin G Gesheff
- Sinai Center for Thrombosis Research, Sinai Hospital, Baltimore, Maryland
| | - Shachi Pandya
- Sinai Center for Thrombosis Research, Sinai Hospital, Baltimore, Maryland
| | - Kirk E Guyer
- Department of Chemistry, Indiana University South Bend, South Bend, Indiana
| | - Anand Singla
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital, Baltimore, Maryland
| | - Peter P Toth
- Department of Preventive Cardiology, CGH Medical Center, Sterling, Illinois; Clinical Family and Community Medicine, University of Illinois College of Medicine, Peoria, Illinois
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital, Baltimore, Maryland.
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Gurbel PA, Kreutz RP, Bliden KP, Tantry US. Platelet Activation and Pneumonia. J Am Coll Cardiol 2015; 65:1492-3. [DOI: 10.1016/j.jacc.2014.12.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/22/2014] [Indexed: 11/29/2022]
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Tantry US, Gesheff M, Liu F, Bliden KP, Gurbel PA. Resistance to antiplatelet drugs: what progress has been made? Expert Opin Pharmacother 2014; 15:2553-64. [DOI: 10.1517/14656566.2014.968126] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gesheff MG, Franzese CJ, Bliden KP, Contino CJ, Rafeedheen R, Tantry US, Gurbel PA. Review of pharmacokinetic and pharmacodynamic modeling and safety of proton pump inhibitors and aspirin. Expert Rev Clin Pharmacol 2014; 7:645-53. [DOI: 10.1586/17512433.2014.945428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Janssen PW, ten Berg JM, Hackeng CM. The use of platelet function testing in PCI and CABG patients. Blood Rev 2014; 28:109-21. [DOI: 10.1016/j.blre.2014.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 03/11/2014] [Indexed: 11/27/2022]
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Tantry US, Jeong YH, Navarese EP, Kubica J, Gurbel PA. Influence of genetic polymorphisms on platelet function, response to antiplatelet drugs and clinical outcomes in patients with coronary artery disease. Expert Rev Cardiovasc Ther 2014; 11:447-62. [DOI: 10.1586/erc.13.20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Aradi D, Storey RF, Komócsi A, Trenk D, Gulba D, Kiss RG, Husted S, Bonello L, Sibbing D, Collet JP, Huber K. Expert position paper on the role of platelet function testing in patients undergoing percutaneous coronary intervention. Eur Heart J 2013; 35:209-15. [PMID: 24067509 PMCID: PMC3896861 DOI: 10.1093/eurheartj/eht375] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Dániel Aradi
- Department of Cardiology, Heart Center Balatonfüred, 2 Gyógy tér, Balatonfüred 8230, Hungary
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McMahon GS, Jones CI, Hayes PD, Naylor AR, Goodall AH. Transient heparin-induced platelet activation linked to generation of platelet 12-lipoxygenase. Findings from a randomised controlled trial. Thromb Haemost 2013; 109:1099-107. [PMID: 23494053 DOI: 10.1160/th12-11-0793] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/31/2013] [Indexed: 11/05/2022]
Abstract
Previously we demonstrated that heparin administration during carotid endarterectomy (CEA) caused a marked, but transient increase in platelet aggregation to arachidonic acid (AA) and adenosine diphosphate (ADP), despite effective platelet cyclo-oxygenase-1 (COX-1) inhibition with aspirin. Here we investigated the metabolism of AA via platelet 12-lipoxygenase (12-LOX) as a possible mediator of the observed transient aspirin resistance, and compared the effects of unfractionated (UFH) and low-molecular-weight (LMWH) heparin. A total of 43 aspirinated patients undergoing CEA were randomised in the trial to 5,000 IU UFH (n=22) or 2,500 IU LMWH (dalteparin, n=21). Platelet aggregation to AA (4x10⁻³) and ADP (3x10⁻⁶) was determined, and the products of the COX-1 and 12-LOX pathways; thromboxane B₂ (TXB₂) and 12-hydroxyeicosatretraenoic acid (12-HETE) were measured in plasma, and in material released from aggregating platelets.Aggregation to AA increased significantly (~10-fold) following heparinisation (p<0.0001), irrespective of heparin type (p=0.33). Significant, but smaller (~2-fold) increases in aggregation to ADP were also seen, which were significantly lower in the platelets of patients randomised to LMWH (p<0.0001). Plasma levels of TxB2 did not rise following heparinisation (p=0.93), but 12-HETE increased significantly in the patients' plasma, and released from platelets stimulated in vitro withADP, with both heparin types (p<0.0001). The magnitude of aggregation to ADP correlated with 12-HETE generation (p=0.03). Heparin administration during CEA generates AA that is metabolised to 12-HETE via the 12-LOX pathway, possibly explaining the phenomenon of transient heparin-induced platelet activation. LMWH has less effect on aggregation and 12-HETE generation than UFH when the platelets are stimulated with ADP.
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Affiliation(s)
- Greg S McMahon
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, LE3 9QP, UK
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Lewis JP, Ryan K, O'Connell JR, Horenstein RB, Damcott CM, Gibson Q, Pollin TI, Mitchell BD, Beitelshees AL, Pakzy R, Tanner K, Parsa A, Tantry US, Bliden KP, Post WS, Faraday N, Herzog W, Gong Y, Pepine CJ, Johnson JA, Gurbel PA, Shuldiner AR. Genetic variation in PEAR1 is associated with platelet aggregation and cardiovascular outcomes. ACTA ACUST UNITED AC 2013; 6:184-92. [PMID: 23392654 DOI: 10.1161/circgenetics.111.964627] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND- Aspirin or dual antiplatelet therapy with aspirin and clopidogrel is a standard therapy for patients who are at increased risk for cardiovascular events. However, the genetic determinants of variable response to aspirin (alone and in combination with clopidogrel) are not known. METHODS AND RESULTS- We measured ex vivo platelet aggregation before and after dual antiplatelet therapy in individuals (n=565) from the Pharmacogenomics of Anti-Platelet Intervention (PAPI) Study and conducted a genome-wide association study of drug response. Significant findings were extended by examining genotype and cardiovascular outcomes in 2 independent aspirin-treated cohorts: 227 percutaneous coronary intervention patients and 1000 patients of the International Verapamil SR/Trandolapril Study (INVEST) Genetic Substudy (INVEST-GENES). Results from the genome-wide association study revealed a strong association between single-nucleotide polymorphisms on chromosome 1q23 and post-dual antiplatelet therapyplatelet aggregation. Further genotyping revealed rs12041331 in the platelet endothelial aggregation receptor-1 (PEAR1) gene to be most strongly associated with dual antiplatelet therapy response (P=7.66×10(-9)). In white and black patients undergoing percutaneous coronary intervention, A-allele carriers of rs12041331 were more likely to experience a cardiovascular event or death compared with GG homozygotes (hazard ratio, 2.62; 95% confidence interval, 0.96-7.10; P=0.059; and hazard ratio, 3.97; 95% confidence interval, 1.10-14.31; P=0.035, respectively). In aspirin-treated INVEST-GENES patients, rs12041331 A-allele carriers had significantly increased risk of myocardial infarction compared with GG homozygotes (odds ratio, 2.03; 95% confidence interval, 1.01-4.09; P=0.048). CONCLUSION- Common genetic variation in PEAR1 may be a determinant of platelet response and cardiovascular events in patients on aspirin alone or in combination with clopidogrel. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00799396 and NCT00370045.
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Affiliation(s)
- Joshua P Lewis
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Hohlfeld T, Saxena A, Schrör K. High on treatment platelet reactivity against aspirin by non-steroidal anti-inflammatory drugs--pharmacological mechanisms and clinical relevance. Thromb Haemost 2012; 109:825-33. [PMID: 23238666 DOI: 10.1160/th12-07-0532] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 11/13/2012] [Indexed: 12/22/2022]
Abstract
Inhibition of platelet function by aspirin results from irreversible inhibition of platelet cyclooxygenase (COX)-1. While sufficient inhibition is obtained at antiplatelet doses (75-325 mg/day) in most (≥95%) treated patients, the antiplatelet effect of aspirin and subsequent cardiovascular risk reduction is much less in clinical settings and disease-dependent. Several reasons for this "high on treatment platelet reactivity" are known. This paper reviews the evidence for an interaction between aspirin and other COX inhibitors, namely non-steroidal anti-inflammatory drugs (NSAIDs). Numerous experimental studies demonstrated a pharmacodynamic interaction between aspirin and NSAIDs. This likely occurs within the hydrophobic substrate channel of platelet COX-1 and might be explained by molecular competition between inhibitor drugs and substrate (arachidonic acid) at overlapping binding sites. This interaction is found with some compounds, notably ibuprofen and dipyrone (metamizole), but not with others, such as diclofenac and acetaminophen (paracetamol). Hence, this interaction is not a class effect of NSAIDs and/or non-steroidal analgesics but rather due to specific structural requirements which still remain to be defined. In vivo studies on healthy subjects and patients tend to confirm this type of interaction as well as large differences between NSAIDs and non-steroidal analgesics, respectively. These interactions may be clinically relevant and may increase the cardiovascular risk in long-term treatment for primary and secondary cardiovascular prevention in patients with chronic inflammation, such as rheumatoid arthritis. These patients have an elevated risk for myocardial infarctions and may require chronic antiplatelet treatment by aspirin in addition to treatment of inflammatory pain.
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Affiliation(s)
- T Hohlfeld
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, Düsseldorf, Germany.
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Fan L, Cao J, Liu L, Li X, Hu G, Hu Y, Zhu B. Frequency, risk factors, prognosis, and genetic polymorphism of the cyclooxygenase-1 gene for aspirin resistance in elderly Chinese patients with cardiovascular disease. Gerontology 2012; 59:122-31. [PMID: 23038044 DOI: 10.1159/000342489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 08/10/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is an important cause of mortality in elderly patients worldwide. Aspirin resistance has been well reported in CVD. OBJECTIVE The frequency, risk factors, prognosis, and genetic polymorphism of the cyclooxygenase-1 (COX-1) gene for aspirin resistance have not been reported in elderly patients with CVD. We therefore undertook this study to evaluate these associations among elderly Chinese patients with CVD. METHODS Four hundred thirty-one elderly Chinese patients with CVD receiving daily aspirin therapy (≥75 mg) over 1 month were enrolled. Platelet aggregation was measured by light transmission aggregometry (LTA) and thromboelastography platelet mapping assay (TEG) using arachidonic acid (AA) as a stimulus. The median follow-up was 1.8 years. RESULTS After the median follow-up, aspirin-resistant patients were at an increased risk of the composite endpoint compared to nonresistant patients by LTAAA + TEGAA (23.7 vs. 9.2%, p = 0.025). Additionally, Cox proportional hazards regression modeling demonstrated that aspirin resistance and cerebrovascular disease were associated with major adverse long-term outcomes (HR for aspirin resistance = 2.31, 95% CI 1.11-4.81, p = 0.026). The variant G-allele of COX-1 rs1330344 (-1676 A/G) significantly increased the risk of aspirin resistance defined by LTAAA + TEGAA (OR = 1.82, 95% CI 1.13- 2.92, p = 0.01). CONCLUSIONS Aspirin resistance, evaluated by LTAAA + TEGAA, is associated with an increased risk of adverse clinical events in elderly Chinese patients with CVD. The variant G-allele of COX-1 rs1330344 is significantly associated with aspirin resistance defined by LTAAA + TEGAA.
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Affiliation(s)
- Li Fan
- Clinical Department of South Building, Chinese PLA General Hospital, Beijing, PR China.
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Cao J, Liu L, Fan L, Chen T, Hu G, Hu Y, Zhu B, Li J, Wang H, Li X. The prevalence, risk factors and prognosis of aspirin resistance in elderly male patients with cardiovascular disease. Aging Male 2012; 15:140-7. [PMID: 22452804 DOI: 10.3109/13685538.2012.666584] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM Aspirin resistance is recognized in different population. However, the prevalence and clinical events of aspirin resistance in elderly male patients with cardiovascular disease (CVD) have not been reported. METHODS We enrolled 304 elderly male patients with CVD receiving daily aspirin therapy (≥ 75 mg) more than 1 month. Platelet aggregation was measured by light transmission aggregometry (LTA) and thrombelastography platelet mapping assay (TEG). The median follow-up time was 1.8 years. The primary outcome was the composite of death, myocardial infarction, unstable angina, stroke and transient ischemic attack. RESULTS By LTA, 25 (8.2%) of elderly patients were aspirin resistant and 106 (34.9%) patients were semiresponders. According to TEG, 62 patients (20.4%) were found to be resistant to aspirin therapy. Of the 62 patients with aspirin resistance by TEG, 21 patients were aspirin resistant by LTA. Twenty-two of the 106 semiresponders by LTA were aspirin resistant by TEG. Patients with aspirin resistance or aspirin semiresponders were at increased risk of the composite outcome compared with aspirin-sensitive patients by LTA (18.3% vs 9.8%, Hazard ratio (HR) = 1.864, 95% confidence interval (CI): 1.046-3.324 p = 0.039). However, aspirin resistance was not associated with an increased risk of clinical vascular events compared to aspirin-sensitive patients by TEG (17.7% vs 10.9%, p = 0.452). In addition, Cox proportional hazard regression modeling demonstrated that aspirin resistance or semiresponders (HR = 3.050, 95% CI: 1.464-6.354, p = 0.003) and diabetes (HR = 2.055, 95% CI: 1.060-3.981, p = 0.033) were associated with major adverse long-term outcomes. CONCLUSIONS Aspirin resistance or semiresponders, defined by LTA, are associated with an increased risk of adverse clinical events in elderly male patients with CVD.
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Affiliation(s)
- Jian Cao
- First Geriatric Cardiology Division, Chinese PLA General Hospital, Beijing, China
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Rollini F, Tello-Montoliu A, Angiolillo DJ. Advances in platelet function testing assessing bleeding complications in patients with coronary artery disease. Platelets 2012; 23:537-51. [DOI: 10.3109/09537104.2012.704649] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Uhry S, Bessereau J, Camoin-Jau L, Paganelli F, Bonello L. Latest evidence in personalized antiplatelet therapy in patients with acute coronary syndromes undergoing percutaneous coronary intervention. Hosp Pract (1995) 2012; 40:104-17. [PMID: 22615085 DOI: 10.3810/hp.2012.04.976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients with acute coronary syndromes undergoing percutaneous coronary intervention, the combination of aspirin and clopidogrel, a P2Y12 adenosine diphosphate (ADP) receptor antagonist, is the gold standard of antiplatelet therapy. Two more potent P2Y12 ADP receptor antagonists are now available. Pharmacodynamic studies have revealed a large interindividual variability in the biological response to clopidogrel that is primarily related to variable active metabolite generation, depending on clinical factors, drug-drug interactions, and genetic polymorphisms. Several assays to measure platelet function are available and have revealed a high prevalence of high on-treatment platelet reactivity (HTPR). Patients exhibiting HTPR after a clopidogrel loading dose have a higher risk of thrombotic recurrence after percutaneous coronary intervention. A recent consensus has defined HTPR for the main platelet assays available (using receiver operating characteristic curve analysis) to define the optimal cutoff value for each assay in order to predict thrombotic recurrences. In this article, we present several lines of evidence that suggest a therapeutic window of platelet reactivity inhibition with P2Y12 ADP receptor antagonists. Such a paradigm shift is supported by the results of the Platelet Inhibition and Patient Outcomes (PLATO) trial and the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction (TRITON-TIMI) 38, which showed the superiority of ticagrelor and prasugrel on thrombotic events compared with clopidogrel; however, these 2 medications had an increased bleeding rate. With the results of these trials, in addition to the evidence of a therapeutic window with P2Y12 ADP receptor antagonists, we summarize the potential of platelet reactivity monitoring and pharmacogenomics to tailor therapy.
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Affiliation(s)
- Sabrina Uhry
- Département de Cardiologie, Hôpital Universitaire Nord de Marseille, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, France
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Simpson SH, Gamble JM, Mereu L, Chambers T. Effect of aspirin dose on mortality and cardiovascular events in people with diabetes: a meta-analysis. J Gen Intern Med 2011; 26:1336-44. [PMID: 21647746 PMCID: PMC3208465 DOI: 10.1007/s11606-011-1757-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Revised: 03/09/2011] [Accepted: 05/03/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pharmacologic evidence suggests adequate antiplatelet activity in diabetic patients requires >100 mg aspirin daily, yet recent trials have used ≤100 mg daily. This meta-analysis explored the relationship between aspirin dose and prevention of cardiovascular events. DATA SOURCES Six electronic databases were searched using database-appropriate terms for aspirin, diabetes, and comparative study from inception until February 2010. REVIEW METHODS Randomized controlled trials and cohort studies comparing aspirin to no antiplatelet therapy were included if they reported cardiovascular events as pre-specified outcomes, aspirin dose, and number of diabetic patients. Studies were stratified by daily aspirin dose (≤100 mg; 101-325 mg; >325 mg) and pooled risk ratios (RR) were calculated using random effects models. All-cause mortality was the primary outcome of interest. Cardiovascular-related mortality, myocardial infarction, and stroke were secondary outcomes. RESULTS Data for diabetic patients were available from 21 studies (n = 17,522). Overall, 1,172 (15.4%) of 7,592 aspirin users and 1,520 (18.4%) of 8,269 controls died (p = 0.31). The pooled RRs were 0.89 (95% CI: 0.72-1.10; p = 0.27) from 13 studies using ≤100 mg (I(2) = 64%); 0.89 (95% CI: 0.61-1.30; p = 0.55) from four studies using 101-325 mg (I(2) = 83%); and 0.96 (95% CI: 0.85-1.08; p = 0.50) from eight studies using >325 mg (I(2) = 0%). Aspirin use was associated with a significantly lower risk of mortality (RR: 0.82; 95% CI: 0.69-0.98; p = 0.03) in 13 secondary prevention studies (I(2) = 27%), whereas aspirin use in seven primary prevention studies (I(2) = 0%) was not (RR: 1.01; 95% CI 0.85-1.19; p = 0.94). A substantial amount of heterogeneity was observed amongst studies in all outcomes. Although inclusion of cohort studies was a major source of heterogeneity, stratification by study design did not reveal a significant dose-response relationship. CONCLUSIONS/INTERPRETATION This summary of available data does not support an aspirin dose-response effect for prevention of cardiovascular events in diabetic patients. However, the systematic review identified an important gap in randomized controlled trial evidence for using 101-325 mg aspirin daily in diabetes.
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Affiliation(s)
- Scot H. Simpson
- Faculty of Pharmacy & Pharmaceutical Sciences, 3126 Dentistry / Pharmacy Centre, University of Alberta, Edmonton, AB Canada T6G 2N8
| | | | - Laurie Mereu
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB Canada
| | - Thane Chambers
- University of Alberta Library Services, Edmonton, AB Canada
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Georgiadis AL, Cordina SM, Vazquez G, Tariq N, Suri MFK, Lakshminarayan K, Adams HP, Qureshi AI. Aspirin treatment failure and the risk of recurrent stroke and death among patients with ischemic stroke. J Stroke Cerebrovasc Dis 2011; 22:100-6. [PMID: 21835634 DOI: 10.1016/j.jstrokecerebrovasdis.2011.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 06/16/2011] [Accepted: 06/21/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The prognostic value of occurrence of ischemic stroke in a patient despite aspirin treatment (aspirin treatment failure) is not known. Our objective was to determine if aspirin treatment failure predicts recurrent ischemic stroke and/or death. METHODS We performed a post-hoc analysis of data from the National Institute of Neurological Disorders and Stroke (NINDS) intravenous recombinant tissue plasminogen activator (rt-PA) trial and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST). Multivariate analysis was used to calculate the odds ratio (OR) of recurrent stroke and recurrent stroke or death for aspirin treatment failure patients for the duration of available follow-up (3 months for TOAST patients; 12 months for NINDS rt-PA trial patients). RESULTS The rate of aspirin treatment failure was 40% and 35% among 1275 patients and 624 patients recruited in the TOAST and NINDS rt-PA trials, respectively. The risk of stroke and death at 3 months and 1 year was not higher among patients classified as aspirin treatment failures among the TOAST (OR 1.1; 95% confidence interval [CI] 0.8-1.6; P = .7) or NINDS rt-PA trial patients (OR 0.8; 95% CI 0.6-1.3; P = .4), respectively. In subgroup analysis, aspirin treatment failure was not found to be associated with recurrent stroke or with the combined endpoint of stroke and death among categories defined by etiologic subtype, including those with large artery atherosclerosis. CONCLUSIONS In a post-hoc analysis of 2 randomized ischemic stroke trials, aspirin treatment failure was not found to be associated with an increased risk of recurrent stroke or death.
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Affiliation(s)
- Alexandros L Georgiadis
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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