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Harm T, Fu X, Frey M, Dittrich K, Brun A, Castor T, Borst O, Müller KAL, Geisler T, Rath D, Lämmerhofer M, Gawaz MP. Machine learning insights into thrombo-ischemic risks and bleeding events through platelet lysophospholipids and acylcarnitine species. Sci Rep 2024; 14:6089. [PMID: 38480746 PMCID: PMC10937715 DOI: 10.1038/s41598-024-56304-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/05/2024] [Indexed: 03/17/2024] Open
Abstract
Coronary artery disease (CAD) often leads to adverse events resulting in significant disease burdens. Underlying risk factors often remain inapparent prior to disease incidence and the cardiovascular (CV) risk is not exclusively explained by traditional risk factors. Platelets inherently promote atheroprogression and enhanced platelet functions and distinct platelet lipid species are associated with disease severity in patients with CAD. Lipidomics data were acquired using mass spectrometry and processed alongside clinical data applying machine learning to model estimates of an increased CV risk in a consecutive CAD cohort (n = 595). By training machine learning models on CV risk measurements, stratification of CAD patients resulted in a phenotyping of risk groups. We found that distinct platelet lipids are associated with an increased CV or bleeding risk and independently predict adverse events. Notably, the addition of platelet lipids to conventional risk factors resulted in an increased diagnostic accuracy of patients with adverse CV events. Thus, patients with aberrant platelet lipid signatures and platelet functions are at elevated risk to develop adverse CV events. Machine learning combining platelet lipidome data and common clinical parameters demonstrated an increased diagnostic value in patients with CAD and might improve early risk discrimination and classification for CV events.
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Affiliation(s)
- Tobias Harm
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Xiaoqing Fu
- Institute of Pharmaceutical Sciences, Eberhard Karls University Tübingen, Auf der Morgenstelle 8, 72076, Tübingen, Germany
| | - Moritz Frey
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Kristina Dittrich
- Institute of Pharmaceutical Sciences, Eberhard Karls University Tübingen, Auf der Morgenstelle 8, 72076, Tübingen, Germany
| | - Adrian Brun
- Institute of Pharmaceutical Sciences, Eberhard Karls University Tübingen, Auf der Morgenstelle 8, 72076, Tübingen, Germany
| | - Tatsiana Castor
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Oliver Borst
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Karin Anne Lydia Müller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany
| | - Michael Lämmerhofer
- Institute of Pharmaceutical Sciences, Eberhard Karls University Tübingen, Auf der Morgenstelle 8, 72076, Tübingen, Germany
| | - Meinrad Paul Gawaz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076, Tübingen, Germany.
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Tian Q, Li SM, Li B. The Pro-Gly or Hyp-Gly Containing Peptides from Absorbates of Fish Skin Collagen Hydrolysates Inhibit Platelet Aggregation and Target P 2Y 12 Receptor by Molecular Docking. Foods 2021; 10:1553. [PMID: 34359423 PMCID: PMC8303285 DOI: 10.3390/foods10071553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/24/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022] Open
Abstract
Previous studies found that the collagen hydrolysates of fish skin have antiplatelet activity, but this component remained unknown. In this study, eleven peptides were isolated and identified in the absorbates of Alcalase-hydrolysates and Protamex®-hydrolysates of skin collagen of H. Molitrix by reverse-phase C18 column and HPLC-MS/MS. Nine of them contained a Pro-Gly (PG) or Hyp-Gly (OG) sequence and significantly inhibited ADP-induced platelet aggregation in vitro, which suggested that the PG(OG) sequence is the core sequence of collagen peptides with antiplatelet activity. Among them, OGSA has the strongest inhibiting activities against ADP-induced platelet aggregation in vitro (IC50 = 0.63 mM), and OGSA inhibited the thrombus formation in rats at a dose of 200 μM/kg.bw with no risk of bleeding. The molecular docking results implied that the OG-containing peptides might target the P2Y12 receptor and form hydrogen bonds with the key sites Cys97, Ser101, and Lys179. As the sequence PG(OG) is abundant in the collagen amino acid sequence of H. Molitrix, the collagen hydrolysates of H. Molitrix might have great potential for being developed as dietary supplements to prevent cardiovascular diseases in the future.
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Affiliation(s)
- Qi Tian
- College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China; (Q.T.); (S.-M.L.)
| | - Shi-Ming Li
- College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China; (Q.T.); (S.-M.L.)
| | - Bo Li
- College of Food Science and Nutritional Engineering, China Agricultural University, Beijing 100083, China; (Q.T.); (S.-M.L.)
- Key Laboratory of Functional Dairy, Ministry of Education, Beijing 100083, China
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Gawaz M, Borst O. Targeted antiplatelet therapy: novel treatment options for ischaemic heart disease. Eur Heart J 2019; 39:117-118. [PMID: 29029141 DOI: 10.1093/eurheartj/ehx559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Otfried-Mueller-Strasse 10, 72076 Tübingen, Germany
| | - Oliver Borst
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Otfried-Mueller-Strasse 10, 72076 Tübingen, Germany
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Qiu J, Lingna W, Jinghong H, Yongqing Z. Oral administration of leeches (Shuizhi): A review of the mechanisms of action on antiplatelet aggregation. JOURNAL OF ETHNOPHARMACOLOGY 2019; 232:103-109. [PMID: 30543914 DOI: 10.1016/j.jep.2018.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/08/2018] [Accepted: 12/08/2018] [Indexed: 05/20/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The leeches (Shuizhi) comprise approximately 680 species distributed throughout the world. As recorded, they have been used as traditional Chinese medicines since the Eastern Han Dynasty, where they were claimed for promote blood circulation and eliminate blood stasis. And have been used to prevent CVDs by exerting multiple effects when orally administered, one of which is the significant inhibition of platelet aggregation. Its ability to exert this effect has been extensively investigated in vivo and in clinical practice. AIM OF STUDY The aim of this review is to summarize and analyse the antiplatelet aggregation mechanisms of leeches by oral administration, support their therapeutic potential and uncover opportunities for future research. MATERIALS AND METHODS Relevant studies from 1980 to 2018 on leeches and platelet aggregation were collected from ancient books, pharmacopoeia, reports and theses via library and internet databases (PubMed, CNKI, Google Scholar, Web of science, SciFinder, Springer and Elsevier). RESULTS Leeches is a unique animal medicine, they can prevent platelet aggregation by inhibiting ADP-induced platelet aggregation, increasing PGI2, decreasing TXA2 and Ca2+, and possibly recovering endothelial cell dysfunction. Leeches also exhibit a strong ability to activate eNOS, leading to an increase in platelet-derived NO. Additionally, the pteridine compounds obtained and identified from leeches have sulfur structure similar to those of other antiplatelet aggregation agents, such as ticlopidine, clopidogrel and ticagrelor. CONCLUSION The present review has focused on the related antiplatelet aggregation mechanisms, dipyridine compounds and toxicological information of leeches. According to the reported data, leeches have emerged as a good source of natural medicine for the treatment of antiplatelet aggregation agents and also make educated guesses for material basis of effects on antiplatelet aggregation. This review can help provide new insights for further studies in association with the development of effective antiplatelet aggregation drugs from natural medicines, especially leeches.
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Affiliation(s)
- Jiang Qiu
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan 250355, China.
| | - Wang Lingna
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan 250355, China.
| | - Hu Jinghong
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan 250355, China.
| | - Zhang Yongqing
- School of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan 250355, China.
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Franken C, Kaiser A, Krüger J, Overbeck K, Mügge A, Neubauer H. Cytochrome P450 2B6 and 2C9 genotype polymorphism – a possible cause of prasugrel low responsiveness. Thromb Haemost 2017; 110:131-40. [DOI: 10.1160/th13-01-0021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 04/04/2013] [Indexed: 01/17/2023]
Abstract
SummaryThe cytochrome P450 (CYP) isoenzymes are essential for the metabolic activation of the prodrug prasugrel. Little is known about the impact of polymorphism of these isoenzymes on the prevalence of prasugrel low responsiveness (PLR) in patients with coronary artery disease. We investigated the frequency of PLR and the question whether PLR is associated with decreased/non-function polymorphisms of the CYP isoenzymes (2C9*2, 2C9*3, 2C19*2, 2C19*3, and 2B6*6). Our study included 355 patients who underwent percutaneous coronary stenting. The patients were initially treated with either prasugrel (n=90; 60/10 mg: loading/daily maintenance dose) or 600/75 mg clopidogrel hydrogensulfate (n=265) in combination with 500/100 mg acetylsalicylic acid (ASA). Platelet function was tested by impedance aggregometry 48 hours after taking the loading dose. Prasugrel achieved on the average significantly higher levels of platelet inhibition as compared to clopidogrel (mean 27.3 U vs 41.2 U). The frequencies of low response for prasugrel, clopidogrel and ASA were 9.8%, 35.1% and 14.9%, respectively. We identified only body mass index to be associated with PLR. PLR was not caused by a loss of ADP P2Y12-receptor function. Half of the patients with PLR were carriers of the reducedfunction allele CYP2B6*6, and 41.7% had the genetic variant CYP2C9*2. The allele CYP2C9*3 was detected in three patients with PLR (25%) and two patients with PLR (16.7%) carried the gene variant CYP2C19*2. In conclusion, the rate of low responders was significantly lower among patients treated with prasugrel than with clopidogrel. PLR are more often carriers of CYP2C9*2 (50% in PLR) than when compared to the prevalence described in literature. Also, there is a trend to an increased frequency of CYP2B6*6 in PLR. In conclusion, CYP2B6 and CYP2C9 polymorphisms seem to be associated with prasugrel low-response.
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Liu X, Wang C, Ding X, Liu X, Li Q, Kong Y. A novel selective inhibitor to thrombin-induced platelet aggregation purified from the leech Whitmania pigra. Biochem Biophys Res Commun 2016; 473:349-354. [DOI: 10.1016/j.bbrc.2016.03.117] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 03/23/2016] [Indexed: 11/26/2022]
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Pankert M, Quilici J, Loundou AD, Verdier V, Lambert M, Deharo P, Bonnet G, Gaborit B, Morange PE, Valéro R, Dutour A, Bonnet JL, Alessi MC, Cuisset T. Impact of obesity and the metabolic syndrome on response to clopidogrel or prasugrel and bleeding risk in patients treated after coronary stenting. Am J Cardiol 2014; 113:54-9. [PMID: 24182762 DOI: 10.1016/j.amjcard.2013.09.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/24/2013] [Accepted: 09/24/2013] [Indexed: 12/30/2022]
Abstract
This study aimed to analyze the impact of body mass index (BMI) and the metabolic syndrome (MS) on responses to clopidogrel or prasugrel and bleeding risk after acute coronary syndrome. The study included 1,542 consecutive patients who underwent coronary stenting (287 clopidogrel 75 mg, 868 clopidogrel 150 mg, and 387 prasugrel 10 mg). Platelet reactivity was assessed 1 month after discharge using platelet reactivity index vasodilator stimulated phosphoprotein (PRI VASP). Three hundred thirty-six patients (21.8%) were obese (BMI ≥30), and we observed higher platelet reactivity associated with higher BMI across thienopyridine regimens. Incidence of high on-treatment platelet reactivity (PRI VASP >50%) was higher in obese than nonobese patients (p <0.05 for all regimens). Conversely, incidence of low on-treatment platelet reactivity with prasugrel therapy (PRI VASP <20%) was lower in obese than nonobese patients: 13% (12 of 93) versus 33% (97 of 294); odds ratio 0.30, 95% confidence interval 0.16 to 0.58; p <0.001. Accordingly, incidence of Bleeding Academic Research Consortium bleeding complications was higher in nonobese than in obese patients: 10% (119 of 1,206) versus 6% (20 of 336); odds ratio 1.7, 95% confidence interval 1.1 to 2.8; p = 0.03. This impaired response was only observed in obese patients with the MS, and obese with the MS had significantly higher platelet reactivity than other obese patients with all regimens (p <0.01). Obese patients without the MS had no significant difference in platelet reactivity compared with nonobese patients. In conclusion, the present study confirmed that BMI has a strong impact on response to clopidogrel and prasugrel with higher incidence of high on-treatment platelet reactivity, lower incidence of low on-treatment platelet reactivity, and lower bleeding complication in obese patients. However, among obese patients, the presence of the MS strongly affects response to antiplatelet agents, indicating that the metabolic status might be a better predictor of platelet inhibition than BMI.
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Affiliation(s)
- Mathieu Pankert
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Jacques Quilici
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Anderson Diendonné Loundou
- Assistance Publique-Hôpitaux de Marseille-Unité d'Aide Méthodologique à la Recherche clinique, Marseille, France
| | - Valentine Verdier
- Assistance Publique-Hôpitaux de Marseille-Equipe Mobile d'Aide à l'Investigation, Marseille, France
| | - Marc Lambert
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Pierre Deharo
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Guillaume Bonnet
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Bénédicte Gaborit
- Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Pierre Emmanuel Morange
- Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France; Laboratoire d'Hématologie, Centre Hospitalo-Universitaire Timone, Marseille, France
| | - René Valéro
- Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France; Département de Nutrition, Maladies Métaboliques, Endocrinologie, Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Anne Dutour
- Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Jean-Louis Bonnet
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France
| | - Marie-Christine Alessi
- Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France; Laboratoire d'Hématologie, Centre Hospitalo-Universitaire Timone, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalo-Universitaire Timone, Marseille, France; Aix-Marseille Univ, Institut national de la santé et de la recherche médicale, Unité Mixte de Recherche 1062, Institut national de la recherche agronomique, Unité Mixte de Recherche 1260, Nutrition, Obesity and Risk of Thrombosis, Faculty of Medicine, Marseille, France.
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Personalized antiplatelet treatment after percutaneous coronary intervention: The MADONNA study. Int J Cardiol 2013; 167:2018-23. [DOI: 10.1016/j.ijcard.2012.05.040] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 05/06/2012] [Indexed: 11/20/2022]
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Langer HF, Geisler T, Gawaz M. Atherothrombosis and Coronary Artery Disease. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00032-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Menozzi A, Lina D, Conte G, Mantovani F, Ardissino D. Antiplatelet therapy in acute coronary syndromes. Expert Opin Pharmacother 2011; 13:27-42. [DOI: 10.1517/14656566.2012.642862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Johnson GJ, Sharda AV, Rao GHR, Ereth MH, Laxson DD, Owen WG. Measurement of Shear-Activated Platelet Aggregate Formation in Non-Anticoagulated Blood: Utility in Detection of Clopidogrel–Aspirin-Induced Platelet Dysfunction. Clin Appl Thromb Hemost 2011; 18:140-9. [DOI: 10.1177/1076029611423387] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We studied the ability of a new instrument, the PlaCor PRT that measures shear-induced platelet aggregation in fingerstick, non-anticoagulated blood without added agonists, to detect platelet dysfunction ex vivo. Platelet reactivity time (PRT) and whole blood aggregation (WBA) were measured in 160 healthy volunteers, before and after aspirin and in 170 participants with established vascular disease or risk factors thereof treated with aspirin ± clopidogrel. Pretreatment PRT and WBA were significantly correlated (collagen r = −.63; arachidonate r = −.65; P < .0001). Following aspirin, the mean PRT increased from 82 to 142 seconds ( P < .0001), and in participants treated with clopidogrel–aspirin, the mean PRT (286 seconds, n = 65) was significantly longer than with aspirin alone (166 seconds, n = 105; P < .001). Only 13% of PRTs of participants treated with clopidogrel and aspirin were within the normal range. We conclude that the PlaCor PRT is a simple, rapid, point-of-care instrument that compares favorably with published descriptions of other platelet function instruments.
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Affiliation(s)
- Gerhard J. Johnson
- Hematology-Oncology Section, Medical Service, Veterans Affairs Health Care System, Minneapolis, MN, USA
- Hematology, Oncology and Transplant Division, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Anish V. Sharda
- Division of Hematology Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Gundu H. R. Rao
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Mark H. Ereth
- Division of Cardiovascular Anesthesia, Mayo Clinic, Rochester, MN, USA
| | - David D. Laxson
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Whyte G. Owen
- Department of Biochemistry and Molecular Biology and Department of Hematology Research, Mayo Clinic, Rochester, MN, USA
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Affiliation(s)
- Meinrad Gawaz
- From the Department of Cardiology and Cardiovascular Medicine, University of Tübingen, Tübingen, Germany
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Neubauer H, Kaiser AFC, Endres HG, Krüger JC, Engelhardt A, Lask S, Pepinghege F, Kusber A, Mügge A. Tailored antiplatelet therapy can overcome clopidogrel and aspirin resistance--the BOchum CLopidogrel and Aspirin Plan (BOCLA-Plan) to improve antiplatelet therapy. BMC Med 2011; 9:3. [PMID: 21226927 PMCID: PMC3033359 DOI: 10.1186/1741-7015-9-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 01/12/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy using acetylsalicylic acid (ASA, aspirin) and clopidogrel is of great importance following coronary stenting. However, the variable platelet inhibitory effectiveness compromises the antithrombotic advantages provided by dual antiplatelet therapy. The aim of this single-center prospective study was to reduce the low response incidence of dual antiplatelet therapy with ASA and clopidogrel according to a prespecified therapy algorithm. METHODS Platelet function testing using whole blood aggregometry (Chronolog 590) was performed 48 hours following coronary stenting (for either acute coronary syndromes or stable coronary artery disease) on 504 patients. The antiplatelet therapy included a loading dose of 600 mg clopidogrel and 500 mg ASA, followed by 75 mg clopidogrel and 100 mg ASA once daily. Clopidogrel low responders (CLR: >5 ohm; adenosine diphosphate (ADP) 5 μM) and/or ASA low responders (ALR: >0 ohm; arachidonic acid 10 μM) were treated according to a structured therapy plan: in the case of CLR, the maintenance + dose was doubled (repeated loading dose followed by 150 mg daily), and when still ineffective ticlopidine or prasugrel, if available and not contraindicated, were used. ALR was treated by increasing the dose to 300 mg in a first step or to 500 mg ASA when the first modification did not take effect sufficiently. In addition, ADP receptor antagonist 2-methylthioadenosine 5'-monophosphate triethylammonium salt (MeSAMP) testing and ASA incubation were performed to rule out either a platelet ADP-receptor defect or an ASA pharmacokinetic resistance. RESULTS Of the total cohort of 504 patients, we detected 30.8% clopidogrel low-responders and 19.4% aspirin low-responders. For ALR, with a dose adjustment of 300 mg ASA daily, 94.6% of ALR were effectively treated and the residual 5.4% by administration of daily dosages of 500 mg ASA. This means that after modification of the ASA maintenance dose, all initial ALRs had an adequate antiplatelet response. The results for clopidogrel revealed that 69% of the CLR were treated effectively by increasing the clopidogrel dose to 150 mg daily. When prasugrel was not available or contraindicated, 12.7% of the remaining low responders showed an adequate result after being switched to ticlopidine. Consequently, by applying the therapy algorithm, we were able to reduce the CLR prevalence by 86.6%. On including prasugrel in the therapy plan, we were finally able to eliminate thienopyridine low response. In addition, no ADP receptor defect was found in this study as a potential reason for CLR. We identified the following factors associated with both CLR and ALR status: acute coronary syndromes, positive troponin values as well as diabetes mellitus and elevated HbA1C values and a higher platelet count. Furthermore, our data revealed for CLR elevated C-reactive protein values and a high PREDICT-score (including an age >65 years, acute coronary syndrome, diabetes mellitus, renal failure, and reduced left ventricular function) as risk factors. The following factors correlated with the risk of ASA low response: patients with elevated hemoglobin, serum creatinine and C-reactive protein values. In addition, medication with nitrates reduced the risk of being CLR. As also holds true for CLR, we found the PREDICT-score to be correlated to the risk of being ALR. However, by far the strongest risk factor for CLR or ALR was the fact of dual resistance. CONCLUSION Following a structured therapy plan based on a "test and treat" strategy, the prevalence of clopidogrel or aspirin low response can be significantly reduced and the risk of inadequate dual antiplatelet therapy minimized.
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Affiliation(s)
- Horst Neubauer
- Cardiovascular Center, Ruhr University Bochum, St, Josef Hospital, Gudrunstr, 56, D-44791 Bochum, Germany.
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