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De Luca G, Verburg A, Hof AV, ten Berg J, Kereiakes DJ, Coller BS, Gibson CM. Current and Future Roles of Glycoprotein IIb-IIIa Inhibitors in Primary Angioplasty for ST-Segment Elevation Myocardial Infarction. Biomedicines 2024; 12:2023. [PMID: 39335537 PMCID: PMC11428685 DOI: 10.3390/biomedicines12092023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 09/30/2024] Open
Abstract
Acute myocardial infarction still represents the major cause of mortality in high-income countries. Therefore, considerable efforts have been focused on the treatment of myocardial infarctions in the acute and long-term phase, with special attention being paid to reperfusion strategies and adjunctive antithrombotic therapies. In fact, despite the successful mechanical recanalization of the epicardial conduit, a substantial percentage of patients still experience poor myocardial reperfusion or acute/subacute in-stent thrombosis. Due the delayed onset of action of currently available oral antiplatelet therapies, glycoprotein (GP) IIb-IIIa inhibitors could be expected to improve clinical outcomes, especially when administrated in the early phase of the infarction, due to the larger platelet composition of fresh thrombi, the dynamic nature of early thrombi, and the larger amount of viable myocardium existing in the early, as compared to a delayed, phase. Considerable evidence has accumulated regarding the benefits from GP IIb-IIIa inhibitors on mortality, especially among high-risk patients and when administered as an upstream strategy. Therefore, based on currently available data, GP IIb-IIIa inhibitors can be considered when the drug can be administered within the first 3 h of symptom onset and among high-risk patients (e.g., those with advanced Killip class or an anterior myocardial infarction). Even though it is not universally accepted, in our opinion, this strategy should be implemented in a pre-hospital setting (in an ambulance) or as soon as possible when arriving at the hospital (at the Emergency Room or Coronary Care Unit, irrespective of whether they are in spoke or hub hospitals). A new, second-generation GP IIb-IIIa inhibitor (zalunfiban) appears to be highly suitable as a pre-hospital pharmacological facilitation strategy at the time of first medical contact due to its favourable features, including its simple subcutaneous administration, rapid onset of action (15 min), and limited time of action (with a half-life of ~1 h), which is likely to minimize the risk of bleeding. The ongoing CELEBRATE trial, including 2499 STEMI patients, may potentially provide compelling data to support the upstream treatment of STEMI patients undergoing mechanical reperfusion. In fact, although the current therapeutic target of increased rates of timely reperfusion has been achieved, the future goal in myocardial infarction treatment should be to achieve the most rapid reperfusion prior to primary percutaneous coronary intervention, thus further minimizing myocardial damage, or, in some cases, even preventing it completely, and improving survival.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Polyclinic G. Martino, University of Messina, 98122 Messina, Italy
- Division of Cardiology, IRCSS Hospital Nuovo-Galeazzi Sant’Ambrogio, 20157 Milan, Italy
| | - Ashley Verburg
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands; (A.V.)
| | - Arnoud van’t Hof
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht, 6229 ER Maastricht, The Netherlands
| | - Jurrien ten Berg
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands; (A.V.)
| | - Dean J. Kereiakes
- The Carl and Edyth Lindner Research Center, The Christ Hospital, Cincinnati, OH 45219, USA
| | - Barry S. Coller
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, NY 10065, USA;
| | - Charles Michael Gibson
- Perfuse Study Group, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02114, USA
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Kuhn AL, Singh J, Puri AS. Dual Antiplatelet Non-Responder: Resistance to Clopidogrel and Ticagrelor. Neurohospitalist 2024; 14:312-315. [PMID: 38894997 PMCID: PMC11181978 DOI: 10.1177/19418744241228630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Background Dual antiplatelet therapy is often required for neurointerventional procedures, especially when a stent or flow diverter is placed in the cervical and intracranial vessels. Patients are usually started on aspirin and clopidogrel given the simplicity of the once daily regimen with reasonable cost. Unfortunately, about a third of patients do not show the desired antiplatelet response to clopidogrel and another agent needs to be introduced. Ticagrelor is a potent antiplatelet medication that has a favorable pharmacological profile and has emerged as a reliable alternative to clopidogrel in recent years. Despite ticagrelor non-responders being rare, they do exist, and identification of these patients is important. Results A 74-year-old female was incidentally found to harbor a right posterior communicating aneurysm which was successfully treated electively with stent-assisted coiling. Platelet inhibition testing revealed non-responsiveness to Clopidogrel. Ticagrelor was initiated but the patient's platelet reactivity unit remained in the normal range. Management algorithms to maximize a patient's ticagrelor response by facilitating enteral absorption were applied but no platelet inhibition was achieved. The patient was eventually identified as a true ticagrelor non-responder. Conclusion Resistance to antiplatelet medication can result in devastating complications with permanent neurological deficits. Ticagrelor non-responders are rare but do exist. Platelet inhibition testing should be part of the preprocedural workup for neurointerventions.
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Affiliation(s)
- Anna Luisa Kuhn
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jasmeet Singh
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ajit S. Puri
- Department of Radiology, Division of Neurointerventional Radiology, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Kordis P, Berden J, Mikuz U, Noc M. Immediate Platelet Inhibition Strategy for Comatose Out-of-Hospital Cardiac Arrest Survivors Undergoing Percutaneous Coronary Intervention and Mild Therapeutic Hypothermia. J Clin Med 2024; 13:2121. [PMID: 38610886 PMCID: PMC11012382 DOI: 10.3390/jcm13072121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Comatose survivors of out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI) and target temperature management (TTM) are at increased risk of stent thrombosis (ST), partly due to delayed platelet inhibition even with more potent P2Y12 agents. We hypothesized that periprocedural cangrelor would induce immediate platelet inhibition, bridging the "P2Y12 inhibition gap". Methods: In our pilot study, we randomized 30 comatose OHCA patients undergoing PCI and TTM (32-34 °C) into cangrelor and control groups. Both groups received unfractioned heparin, acetylsalicylic acid, and ticagrelor via enteral tube. The cangrelor group also received an intravenous bolus of cangrelor followed by a 4 h infusion. Platelet inhibition was measured using VerifyNow® and Multiplate® ADP at baseline and 1, 3, 5, and 8 h post PCI. Results: Patient characteristics did not differ between groups. VerifyNow® showed significantly decreased platelet reactivity with cangrelor at 1 h (30 vs. 221 PRU; p < 0.001) and 3 h (24 vs. 180 PRU; p < 0.001), with differences at 5 and 8 h. Similarly, the proportion of patients with high on-treatment platelet reactivity (HPR) in the cangrelor group was significantly lower at 1 h (0% vs. 67%; p < 0.001) and 3 h (0% vs. 47%; p = 0.007). Multiplate® ADP was also decreased at 1 h (14 vs. 48 U; p < 0.001) and 3 h (11 vs. 42 U; p = 0.001), with no difference at 5 and 8 h. The occurrence of bleeding events was similar in both groups. Conclusions: Cangrelor safely induced immediate and profound platelet inhibition. We observed no significant drug-drug interaction with ticagrelor.
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Affiliation(s)
- Peter Kordis
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Jernej Berden
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Ursa Mikuz
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (P.K.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Droppa M, Geisler T. Optimal Antithrombotic Strategies in Cardiogenic Shock. J Clin Med 2024; 13:277. [PMID: 38202284 PMCID: PMC10779586 DOI: 10.3390/jcm13010277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Cardiogenic shock (CS) represents a critical condition with a high mortality rate. The most common cause of CS is coronary artery disease, and patients typically present with myocardial infarction, necessitating immediate treatment through percutaneous coronary intervention (PCI) and often requiring mechanical circulatory support. CS is associated with a prothrombotic situation, while on the other hand, there is often a significant risk of bleeding. This dual challenge complicates the selection of an optimal antithrombotic strategy. The choice of antithrombotic agents must be personalized, taking into consideration all relevant conditions. Repeated risk assessment, therapeutic monitoring, and adjusting antithrombotic therapy are mandatory in these patients. This review article aims to provide an overview of the current evidence and practical guidance on antithrombotic strategies in the context of CS.
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Affiliation(s)
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tuebingen, 72076 Tuebingen, Germany
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Holzer M, Poole JE, Lascarrou JB, Fujise K, Nichol G. A Commentary on the Effect of Targeted Temperature Management in Patients Resuscitated from Cardiac Arrest. Ther Hypothermia Temp Manag 2023; 13:102-111. [PMID: 36378270 PMCID: PMC10625468 DOI: 10.1089/ther.2022.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The members of the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force have written a comprehensive summary of trials of the effectiveness of induced hypothermia (IH) or targeted temperature management (TTM) in comatose patients after cardiac arrest (CA). However, in-depth analysis of these studies is incomplete, especially since there was no significant difference in primary outcome between hypothermia versus normothermia in the recently reported TTM2 trial. We critically appraise trials of IH/TTM versus normothermia to characterize reasons for the lack of treatment effect, based on a previously published framework for what to consider when the primary outcome fails. We found a strong biologic rationale and external clinical evidence that IH treatment is beneficial. Recent TTM trials mainly included unselected patients with a high rate of bystander cardiopulmonary resuscitation. The treatment was not applied as intended, which led to a large delay in achievement of target temperature. While receiving intensive care, sedative drugs were likely used that might have led to increased neurologic damage as were antiplatelet drugs that could be associated with increased acute stent thrombosis in hypothermic patients. It is reasonable to still use or evaluate IH treatment in patients who are comatose after CA as there are multiple plausible reasons why IH compared to normothermia did not significantly improve neurologic outcome in the TTM trials.
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Affiliation(s)
- Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeanne E. Poole
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | | | - Ken Fujise
- Harborview Medical Center, Heart Institute, University of Washington, Seattle, Washington, USA
| | - Graham Nichol
- Departments of Medicine and Emergency Medicine, University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, Washington, USA
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Baldetti L, Nardelli P, Ajello S, Melisurgo G, Calabrò MG, Pieri M, Scandroglio AM. Anti-thrombotic Therapy With Cangrelor and Bivalirudin in Venoarterial Extracorporeal Membrane Oxygenation Patients Undergoing Percutaneous Coronary Intervention: A Single-Center Experience. ASAIO J 2023; 69:e346-e350. [PMID: 36490373 DOI: 10.1097/mat.0000000000001871] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
VA-ECMO is commonly used for patients in cardiogenic shock (CS) or refractory cardiac arrest (CA) undergoing PCI for ACS. In this setting at high risk of both thrombotic and hemorrhagic complications, optimal anti-thrombotic therapy remains ill-defined. We hypothesized that an anti-thrombotic therapy comprising a parenteral anticoagulant (bivalirudin) and a parenteral anti-platelet agent (cangrelor) may prove safe and effective in this scenario. From November 2019 to December 2021, 14 patients received at least one dose of cangrelor (starting dose: 0.125 μg/kg/min) plus bivalirudin, without background aspirin, in the context of PCI and VA-ECMO for ACS-related CS/CA, and were included in this study. Efficacy endpoint was occurrence of thrombotic events and safety endpoint was major bleeding occurrence. Median age was 58 years. The majority (64%) presented with refractory CA. A thrombotic event occurred in 14%, while major bleeding occurred in 21% patients. One patient experienced arterial thrombosis after VA-ECMO arterial cannula removal, another experienced ischemic cerebellar stroke without functional sequelae. Bleeding events were: 29% BARC 3a, 14% BARC 3b, and 7% BARC 5b. Overall in-hospital mortality was 50%. Cangrelor was continued for 5 (4-10) days; temporary discontinuation was necessary in 36%, either for VA-ECMO cannula removal or for bleeding events. A low dose of cangrelor, associated with standard-intensity anticoagulation with bivalirudin was a feasible anti-thrombotic strategy in patients undergoing PCI during VA-ECMO support for ACS-related CS/CA. Bleeding events rates outweighed thrombotic events rates in this critically-ill population, although the observed rates were lowest among available studies.
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Affiliation(s)
- Luca Baldetti
- From the Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Melisurgo
- Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Calabrò
- Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Cardiac Surgery Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Rakowski T, Węgiel M, Malinowski KP, Siudak Z, Zasada W, Zdzierak B, Tokarek T, Rzeszutko Ł, Dudek D, Bartuś S, Surdacki A, Dziewierz A. Thrombus containing lesions strategies during primary percutaneous coronary interventions in ST-segment elevation myocardial infarction: insights from ORPKI National Registry. J Thromb Thrombolysis 2023:10.1007/s11239-023-02811-z. [PMID: 37093352 DOI: 10.1007/s11239-023-02811-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2023] [Indexed: 04/25/2023]
Abstract
In the era of potent P2Y12 inhibitors, according to current guidelines, treatment with glycoprotein IIb/IIIa inhibitors (GPIs) should be limited to bail-out and/or highly thrombotic situations. Similarly, the recommendation for aspiration thrombectomy (AT) is downgraded to very selective use. We examine the prevalence, and predictors of GPI and AT use in STEMI patients referred to primary percutaneous coronary intervention (PCI). Data on 116,873 consecutive STEMI patients referred to primary PCI in Poland between 2015 and 2020 were analyzed. GPIs were administered in 29.3%, AT was used in 11.6%, and combined treatment with both in 6.1%. There was a mild trend toward a decrease in GPI and AT usage during the analyzed years. On the contrary, there was a rapid growth of the ticagrelor/prasugrel usage rate from 6.5 to 48.1%. Occluded infarct-related artery at baseline and no-reflow during PCI were the strongest predictors of GPI administration (OR 2.3; 95% CI 2.22-2.38 and OR 3.47; 95% CI 3.13-3.84, respectively) and combined usage of GPI and AT (OR 4.4; 95% CI 4.08-4.8 and OR 3.49; 95% CI 3.08-3.95 respectively) in a multivariate logistic regression model. Similarly, the administration of ticagrelor/prasugrel was an independent predictor of both adjunctive treatment strategies. In STEMI patients in Poland, GPIs are selectively used in one in four patients during primary PCI, and the combined usage of GPI and AT is marginal. Despite the rapid growth in potent P2Y12 inhibitors usage in recent years, GPIs are selectively used at a stable rate during PCI in highly thrombotic lesions.
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Affiliation(s)
- Tomasz Rakowski
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688, Kraków, Poland
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Michał Węgiel
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Krzysztof P Malinowski
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Kraków, Poland
| | - Zbigniew Siudak
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Wojciech Zasada
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Barbara Zdzierak
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Tomasz Tokarek
- Center for Invasive Cardiology, Electrotherapy and Angiology, Nowy Sacz, Poland
- Center for Innovative Medical Education, Jagiellonian University Medical College, Kraków, Poland
| | - Łukasz Rzeszutko
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688, Kraków, Poland
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Dariusz Dudek
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688, Kraków, Poland
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Stanisław Bartuś
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688, Kraków, Poland
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Andrzej Surdacki
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688, Kraków, Poland
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
| | - Artur Dziewierz
- 2nd Department of Cardiology, Institute of Cardiology, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688, Kraków, Poland.
- Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland.
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Khanafer A, Cimpoca A, Bhogal P, Babiy-Pachomow O, Kurucz P, Ganslandt O, Henkes H. Low incidence of hemorrhagic complications both during and after surgical procedures in patients maintained on prasugrel single antiplatelet therapy. J Neuroradiol 2023; 50:65-73. [PMID: 35306003 DOI: 10.1016/j.neurad.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Prasugrel (Pra) is a third-generation thienopyridine that inhibits platelet aggregation via irreversible blockade of P2Y12 receptors. While several published studies have examined the use of Pra and acetylsalicylic acid (ASA) in coronary and neurovascular stenting procedures, there is only anecdotal evidence regarding the use of Pra as single antiplatelet therapy (SAPT) in open surgical procedures. This topic has become important because previous studies have revealed that neurovascular devices with antithrombotic coatings can be implanted using non-invasive procedures in patients maintained on Pra SAPT. MATERIAL AND METHODS Patients who underwent open surgery under Pra SAPT between March 2020 and February 2022 were evaluated retrospectively. Adequate platelet inhibition both before and after the procedures was verified in all patients using Multiplate (Roche Diagnostics) and VerifyNow (Accriva) tests. Intraoperative and postoperative hemorrhagic events were recorded based on reviews of the procedure reports and interviews with the surgeons. RESULTS The study enrolled 21 patients who underwent 23 open surgical procedures while maintained on Pra SAPT. The procedures included one extirpation of a brain arteriovenous malformation, seven extra-intracranial bypass surgeries, four ventriculoperitoneal shunts, one eye enucleation for an intractable orbital infection, two gastrostomies, one bone flap reinsertion after craniectomy, one decompressive craniectomy, one case requiring cranial surgical wound care, one colporrhaphy, one transurethral resection of urinary bladder cancer, two tumor oophorectomy/hysterectomy procedures, and one aneurysm clipping. None of the 23 procedures resulted in excessive intraoperative or postoperative hemorrhage. CONCLUSION In a small retrospective series of patients who required antiplatelet therapy for neurovascular indications, Pra SAPT resulted in no significant increase in the incidence of perioperative and postoperative hemorrhagic complications.
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Affiliation(s)
- Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany.
| | | | - Paul Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | | | - Peter Kurucz
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany; Medical Faculty, Universität Duisburg-Essen, Essen, Germany
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Nichol G, West A. Contemporary Approaches to Reducing Morbidity and Mortality in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2022; 80:1799-1801. [DOI: 10.1016/j.jacc.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 01/07/2023]
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Dai L, Xu J, Jiang Y, Chen K. Impact of Prasugrel and Ticagrelor on Platelet Reactivity in Patients With Acute Coronary Syndrome: A Meta-Analysis. Front Cardiovasc Med 2022; 9:905607. [PMID: 35757353 PMCID: PMC9226562 DOI: 10.3389/fcvm.2022.905607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThis meta-analysis mainly aimed to compare the impact of prasugrel and ticagrelor on platelet reactivity (PR) in patients with acute coronary syndrome (ACS).MethodsWe searched four electronic databases to identify randomized controlled trials and cohort studies comparing the impact of prasugrel and ticagrelor on PR in patients with ACS. We performed group analyses according to three detection methods, drug dose [loading dose (LD) and maintenance dose (MTD)] and LD effect time, and assessed the robustness of the results through sensitivity analysis.ResultsTwenty-five studies with 5,098 patients were eligible. After LD, the incidence of high on-treatment platelet reactivity (HTPR) of ticagrelor was significantly lower than that of prasugrel within 6–18 h based on vasodilator-stimulated phosphoprotein (VASP) test [RR = 0.25 (0.07, 0.85), P = 0.03], there was no significant difference between ticagrelor and prasugrel in the following results: platelets inhibitory effect within 24–48 h based on VerifyNow P2Y12 (VN) assay (P = 0.11) and VASP test (P = 0.20), and the incidence of HTPR within 2–6 h based on VN assay (P = 0.57) and within 24–48 h based on VN assay (P = 0.46) and VASP test (P = 0.72), the incidence of low on-treatment platelet reactivity (LTPR) within 6–18 h based on VASP test (P = 0.46) and 48 h based on VN assay (P = 0.97) and VASP test (P = 0.73). After MTD, the platelet inhibitory effect of ticagrelor was stronger than that of prasugrel based on VN assay [WMD = −41.64 (−47.16, −36.11), P < 0.00001]and VASP test [WMD = −9.10 (−13.88, −4.32), P = 0.0002], the incidence of HTPR of ticagrelor was significantly lower than that of prasugrel based on VN assay [RR = 0.05 (0.02, 0.16), P < 0.00001], the incidence of LTPR of ticagrelor was significantly higher than prasugrel based on VN assay [RR = 6.54 (4.21, 10.14), P < 0.00001] and VASP test [RR = 2.65 (1.78, 3.96), P < 0.00001], the results of Multiple Electrode Aggregometry (MEA) test was inconsistent with the other two detection methods in platelet inhibitory effect and the incidence of HTPR and LTPR. There was no significant difference between ticagrelor and prasugrel in the following clinical outcomes: all-cause death (P = 0.86), cardiovascular death (P = 0.49), myocardial infarction (P = 0.67), stroke (P = 0.51), target vessel revascularization (P = 0.51), stent thrombosis (P = 0.90), TIMI major bleeding (P = 0.86) and bleeding BARC type ≥ 2 (P = 0.77). The risk of bleeding BARC type 1 of ticagrelor was significantly higher than prasugrel [RR = 1.44 (1.03, 2.02), P = 0.03].ConclusionsCompared with prasugrel, ticagrelor might have a stronger platelet inhibition effect, with a lower incidence of HTPR and a higher incidence of LTPR and bleeding BARC type 1, while there might be no significant difference in the risk of thrombosis/ischemic, bleeding BARC Type ≥ 2 and TIMI major bleeding. A higher incidence of LTPR might indicate a higher risk of bleeding BARC type 1. The results of VN assay were consistent with that of VASP test, and not with the MEA test.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022304205, identifier: CRD42022304205.
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Affiliation(s)
- Lulu Dai
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jiawei Xu
- Graduate School of Beijing University of Chinese Medicine, Beijing, China
| | - Yuerong Jiang
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Yuerong Jiang
| | - Keji Chen
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Keji Chen
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Patlolla SH, Kandlakunta H, Kuchkuntla AR, West CP, Murad MH, Wang Z, Kochar A, Rab ST, Gersh BJ, Holmes DR, Zhao DX, Vallabhajosyula S. Newer P2Y 12 Inhibitors vs Clopidogrel in Acute Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock: A Systematic Review and Meta-analysis. Mayo Clin Proc 2022; 97:1074-1085. [PMID: 35662424 DOI: 10.1016/j.mayocp.2022.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/18/2022] [Accepted: 02/15/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y12 inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS). PATIENTS AND METHODS MEDLINE, EMBASE, and the Cochrane Library were queried systematically from inception to January 2021 for comparative studies of adults (≥18 years) with AMI-CA/CS receiving DAPT with newer P2Y12 inhibitors as opposed to clopidogrel. We compared outcomes (30-day or in-hospital and 1-year all-cause mortality, major bleeding, and definite stent thrombosis) of newer P2Y12 inhibitors and clopidogrel in patients with AMI-CA/CS. RESULTS Eight studies (1 randomized trial and 7 cohort studies) comprising 1100 patients (695 [63.2%] receiving clopidogrel and 405 [36.8%] receiving ticagrelor or prasugrel) were included. The population was mostly male (68.5%-86.7%). Risk of bias was low for these studies, with between-study heterogeneity and subgroup differences not statistically significant. Compared with the clopidogrel cohort, the newer P2Y12 cohort had lower rates of early mortality (odds ratio [OR], 0.60; 95% CI, 0.45 to 0.81; P=.001) (7 studies) and 1-year mortality (OR, 0.51; 95% CI, 0.36 to 0.71; P<.001) (3 studies). We did not find a significant difference in major bleeding (OR, 1.21; 95% CI, 0.71 to 2.06; P=.48) (6 studies) or definite stent thrombosis (OR, 2.01; 95% CI, 0.63 to 6.45; P=.24) (7 studies). CONCLUSION In patients with AMI-CA/CS receiving DAPT, compared with clopidogrel, newer P2Y12 inhibitors were associated with lower rates of early and 1-year mortality. Data on major bleeding and stent thrombosis were inconclusive.
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Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Harika Kandlakunta
- Department of Medicine, Staten Island University Hospital, Staten Island, NY
| | | | - Colin P West
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ajar Kochar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - S Tanveer Rab
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
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12
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Effron MB. Importance of More Potent Antiplatelet Therapy in Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock. Mayo Clin Proc 2022; 97:1041-1043. [PMID: 35662420 DOI: 10.1016/j.mayocp.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mark B Effron
- John Ochsner Heart and Vascular Institute, University of Queensland-Ochsner Clinical School, New Orleans, LA.
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13
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Poppe M, Clodi C, Schriefl C, Mueller M, Sunder-Plaßmann R, Reiter B, Rechenmacher M, van Os W, van Hasselt JGC, Holzer M, Herkner H, Schwameis M, Jilma B, Schoergenhofer C, Weiser C. Targeted temperature management after cardiac arrest is associated with reduced metabolism of pantoprazole - A probe drug of CYP2C19 metabolism. Biomed Pharmacother 2021; 146:112573. [PMID: 34959115 DOI: 10.1016/j.biopha.2021.112573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest. METHODS This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling. RESULTS 16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8-4.8 h) in P1, 2.8 h (2.1-6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 - 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3. CONCLUSION CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations.
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Affiliation(s)
- Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | | | - Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Raute Sunder-Plaßmann
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | | | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Austria
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14
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Laurent D, Dodd WS, Small C, Gooch MR, Ghosh R, Goutnik M, Blatt T, Porche K, Geh N, Adamczak S, Polifka AJ, Brzezicki G, Hoh B, Chalouhi N. Ticagrelor resistance: a case series and algorithm for management of non-responders. J Neurointerv Surg 2021; 14:179-183. [PMID: 34215660 DOI: 10.1136/neurintsurg-2021-017638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023]
Abstract
The placement of cervical and intracranial stents requires the administration of antiplatelet drugs to prevent thromboembolic complications. Ticagrelor has emerged as the most widely used alternative in clopidogrel non-responders owing to its potent antiplatelet effects. Because ticagrelor does not require hepatic activation, many neurointerventionalists choose to forgo laboratory testing of platelet inhibition. In rare instances, patients may not achieve adequate platelet inhibition following ticagrelor administration. In this paper we review the mechanism of action of ticagrelor and its use in cerebrovascular procedures. We present two cases of ticagrelor non-responsiveness from two high-volume cerebrovascular centers, discuss their management, and propose an algorithm for managing ticagrelor non-responsiveness.
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Affiliation(s)
- Dimitri Laurent
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - William S Dodd
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Coulter Small
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - M Reid Gooch
- Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ritam Ghosh
- Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Michael Goutnik
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Ken Porche
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Ndi Geh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Stephanie Adamczak
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam J Polifka
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Grzegorz Brzezicki
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Brian Hoh
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Nohra Chalouhi
- Lillian S Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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15
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van der Sangen NMR, Cheung HY, Verouden NJW, Appelman Y, Beijk MAM, Claessen BEPM, Delewi R, Knaapen P, Lemkes JS, Nap A, Vis MM, Kikkert WJ, Henriques JPS. Cangrelor Use in Routine Practice: A Two-Center Experience. J Clin Med 2021; 10:2829. [PMID: 34206905 PMCID: PMC8269409 DOI: 10.3390/jcm10132829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 12/04/2022] Open
Abstract
Cangrelor is the first and only intravenous P2Y12-inhibitor and is indicated when (timely) administration of an oral P2Y12 inhibitor is not feasible in patients undergoing percutaneous coronary intervention (PCI). Our study evaluated the first years of cangrelor use in two Dutch tertiary care centers. Cangrelor-treated patients were identified using a data-mining algorithm. The cumulative incidences of all-cause death, myocardial infarction, definite stent thrombosis and major bleeding at 48 h and 30 days were assessed using Kaplan-Meier estimates. Predictors of 30-day mortality were identified using uni- and multivariable Cox regression models. Between March 2015 and April 2021, 146 patients (median age 63.7 years, 75.3% men) were treated with cangrelor. Cangrelor was primarily used in ST-segment elevation myocardial infarction (STEMI) patients (84.2%). Approximately half required cardiopulmonary resuscitation (54.8%) or mechanical ventilation (48.6%). The cumulative incidence of all-cause death was 11.0% and 25.3% at 48 h and 30 days, respectively. Two cases (1.7%) of definite stent thrombosis, both resulting in myocardial infarction, occurred within 30 days, but after 48 h. No other cases of recurrent myocardial infarction transpired within 30 days. Major bleeding occurred in 5.6% and 12.5% of patients within 48 h and 30 days, respectively. Cardiac arrest at presentation was an independent predictor of 30-day mortality (adjusted hazard ratio 5.20, 95%-CI: 2.10-12.9, p < 0.01). Conclusively, cangrelor was used almost exclusively in STEMI patients undergoing PCI. Even though cangrelor was used in high-risk patients, its use was associated with a low rate of stent thrombosis.
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Affiliation(s)
- Niels M. R. van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Ho Yee Cheung
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Niels J. W. Verouden
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Marcel A. M. Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Bimmer E. P. M. Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Jorrit S. Lemkes
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - M. Marije Vis
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Wouter J. Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, 1091 AC Amsterdam, The Netherlands
| | - José P. S. Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
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16
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Scherer C, Lüsebrink E, Kupka D, Stocker TJ, Stark K, Kleeberger J, Orban M, Kellnar A, Petzold T, Deseive S, Krieg K, Würbel S, Kika S, Istrefi M, Brunner S, Braun D, Hagl C, Hausleiter J, Massberg S, Sibbing D, Orban M. ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock. Platelets 2021; 33:371-380. [PMID: 33941008 DOI: 10.1080/09537104.2021.1913577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock. The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock and with available on-treatment ADP-induced platelet aggregation measurements. Out of 233 patients, 74 suffered from a severe BARC3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (p < .001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU). An optimal cutoff value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, the use of VA-ECMO (HR 1.972) or coaxial left ventricular pump (HR 2.593), first lactate (HR 1.093 per mmol/l) and thrombocyte count (HR 0.994 per G/l) were independent predictors of BARC≥3 bleedings. In conclusion, lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in cardiogenic shock warrants further investigation.
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Affiliation(s)
- Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Danny Kupka
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Thomas J Stocker
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Konstantin Stark
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Jan Kleeberger
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Mathias Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Antonia Kellnar
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Petzold
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Simon Deseive
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Kathrin Krieg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Sara Würbel
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Sara Kika
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Mario Istrefi
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Brunner
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Braun
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Dirk Sibbing
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
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17
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Spirito A, Gargiulo G, Siontis G, Mitsis A, Billinger M, Windecker S, Valgimigli M. Cardiovascular mortality and morbidity in patients undergoing percutaneous coronary intervention after out-of-hospital cardiac arrest: a systematic review and meta-analysis. EUROINTERVENTION 2021; 16:e1245-e1253. [PMID: 32624462 PMCID: PMC9724882 DOI: 10.4244/eij-d-20-00221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this meta-analysis was to appraise the burden of cardiovascular mortality and morbidity among patients undergoing percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest (OHCA). METHODS AND RESULTS This was a meta-analysis of studies assessing the cardiovascular mortality or at least one other pre-defined outcome in OHCA patients undergoing PCI. Forty-nine studies with a total of 301,902 patients (73,634 OHCA and 228,268 non-OHCA patients) were included. Compared to non-OHCA patients, all-cause mortality was higher in OHCA patients (29% vs 4%). The cause of 39% of deaths among OHCA patients was cardiovascular: PCI was more frequently unsuccessful (9.2% vs 7.6%) and there were higher rates of stent thrombosis (2.9% vs 0.8%), myocardial infarction (1.7% vs 1.4%), relevant bleeding (10.2% vs 2.1%) and stroke (1.7% vs 0.5%). OHCA patients compared to non-OHCA patients had a higher risk of all-cause mortality (risk ratio [RR] 6.4, 95% CI: 5.5-7.4), cardiovascular death (4.6, 1.1-19), unsuccessful coronary revascularisation (1.4, 1.1-1.7), stent thrombosis (3.8, 0.6-22.7), myocardial infarction (1.4, 1.1-1.7), relevant bleeding (3.2, 2.5-4.1) and stroke (3.1, 2.3-4.3). CONCLUSIONS Almost one third of OHCA patients undergoing PCI die and more than one third of the fatalities are attributable to cardiovascular causes. The burden of ischaemic and bleeding complications was consistently higher and the success rates of PCI lower among OHCA as compared to non-OHCA patients.
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Affiliation(s)
- Alessandro Spirito
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giuseppe Gargiulo
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland,Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - George Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andreas Mitsis
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michael Billinger
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, CH-6900 Lugano, Switzerland
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18
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Infeld M, Friede KA, San TR, Knickerbocker HJ, Ginsburg GS, Ortel TL, Voora D. Platelet reactivity in response to aspirin and ticagrelor in African-Americans and European-Americans. J Thromb Thrombolysis 2021; 51:249-259. [PMID: 33159252 PMCID: PMC7889728 DOI: 10.1007/s11239-020-02327-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/19/2022]
Abstract
Platelet gene polymorphisms are associated with variable on-treatment platelet reactivity and vary by race. Whether differences in platelet reactivity and aspirin or ticagrelor exist between African-American and European-Americans remains poorly understood. Biological samples from three prior prospective antiplatelet challenge studies at the Duke Clinical Research Unit were used to compare platelet reactivity between African-American and European-American subjects. Platelet reactivity at baseline, on-aspirin, on-ticagrelor, and the treatment effect of aspirin or ticagrelor were compared between groups using an adjusted mixed effects model. Compared with European-Americans (n = 282; 50% female; mean ± standard deviation age, 50 ± 16), African-Americans (n = 209; 67% female; age 48 ± 12) had lower baseline platelet reactivity with platelet function analyzer-100 (PFA-100) (p < 0.01) and with light transmission aggregometry (LTA) in response to arachidonic acid (AA), adenosine diphosphate (ADP), and epinephrine agonists (p < 0.05). African-Americans had lower platelet reactivity on aspirin in response to ADP, epinephrine, and collagen (p < 0.05) and on ticagrelor in response to AA, ADP, and collagen (p < 0.05). The treatment effect of aspirin was greater in European-Americans with an AA agonist (p = 0.002). Between-race differences with in vitro aspirin mirrored those seen in vivo. The treatment effect of ticagrelor was greater in European-Americans in response to ADP (p < 0.05) but with collagen, the treatment effect was greater for African-Americans (p < 0.05). Platelet reactivity was overall lower in African-Americans off-treatment, on aspirin, and on ticagrelor. European-Americans experienced greater platelet suppression on aspirin and on ticagrelor. The aspirin response difference in vivo and in vitro suggests a mechanism intrinsic to the platelet. Whether the absolute level of platelet reactivity or the degree of platelet suppression after treatment is more important for clinical outcomes is uncertain.
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Affiliation(s)
- Margaret Infeld
- Division of Cardiology, Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Kevin A Friede
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Tan Ru San
- Department of Cardiology, National Heart Centre, Singapore, Singapore
| | - Holly J Knickerbocker
- Center for Applied Genomics & Precision Medicine, Duke University, 2187 CIEMAS, Campus Box 3382, Durham, NC, 27708, USA
| | - Geoffrey S Ginsburg
- Center for Applied Genomics & Precision Medicine, Duke University, 2187 CIEMAS, Campus Box 3382, Durham, NC, 27708, USA
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Thomas L Ortel
- Division of Hematology, Duke University, Durham, NC, USA
| | - Deepak Voora
- Center for Applied Genomics & Precision Medicine, Duke University, 2187 CIEMAS, Campus Box 3382, Durham, NC, 27708, USA.
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA.
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19
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Petrov A, Rentsenkhuu G, Nota B, Ganzorig E, Regzengombo B, Jagusch S, Henkes E, Henkes H. Initial experience with the novel p64MW HPC flow diverter from a cohort study in unruptured anterior circulation aneurysms under dual antiplatelet medication. Interv Neuroradiol 2021; 27:42-50. [PMID: 32640858 PMCID: PMC7874381 DOI: 10.1177/1591019920939845] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE p64MW HPC is a new low-profile flow diverter with reduced thrombogenicity due to hydrophilic coating. The purpose of this study was to evaluate its safety and efficacy in Mongolian patients under dual antiplatelet therapy. METHODS Consecutive patients with unruptured anterior circulation aneurysms were prospectively enrolled. All patients received aspirin and clopidogrel before and six months after the procedure, followed by lifelong aspirin medication. High platelet reactivity (VerifyNow) did not trigger further action. The safety and efficacy endpoints were clinical outcome and aneurysm occlusion. RESULTS In 29 patients (26 female, median age 57 years), 46 aneurysms (neck width 3.3 mm, fundus diameter 3.7 mm, median) were treated. Dual platelet function inhibition was confirmed in eight patients (28%). The response to Clopidogrel was between 100 and 239 P2Y12 reaction units (VerifyNow) in 13 patients (45%). Non-response to at least one drug was found in 8 of 29 patients (28%). One collapsed p64MW HPC required balloon angioplasty. No other periprocedural thrombus formation occurred. Postprocedural MRI revealed lesions with diffusion restriction in 3 of 29 patients. Digital subtraction angiography after three months for 42 of 46 (91%) aneurysms showed an adequate aneurysm occlusion in 25 (60%). Distal p64MW HPC migration of 3 implants was retreated with another p64MW HPC. Follow-up digital subtraction angiography of 26 of 46 (57%) aneurysms after six months showed adequate aneurysm occlusion in 22 (85%). Significant in-stent stenosis or thrombosis, morbidity or mortality was not encountered. CONCLUSION p64MW HPC implantation in patients under dual antiplatelet therapy with or without dual platelet function inhibition has a low procedural complication rate. The early aneurysm occlusion rate is high.
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Affiliation(s)
- Andrey Petrov
- Vascular Neurosurgery Department,
Russian Polenov Neurosurgical Institute, Branch of National Medical Research
Center “Almazov”, St. Petersburg, Russia
| | | | - Baatarjan Nota
- Department of Angiography, Shastin
Central Hospital, Ulaanbaatar, Mongolia
| | - Erdenebat Ganzorig
- Department of Angiography, Shastin
Central Hospital, Ulaanbaatar, Mongolia
| | | | | | - Elina Henkes
- Neuroradiological Clinic, Klinikum
Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum
Stuttgart, Stuttgart, Germany
- University Duisburg-Essen,
Medizinische Fakultät, Essen, Germany
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20
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Guedeney P, Collet JP. Antithrombotic Therapy in Acute Coronary Syndromes: Current Evidence and Ongoing Issues Regarding Early and Late Management. Thromb Haemost 2021; 121:854-866. [PMID: 33506483 DOI: 10.1055/s-0040-1722188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y12 inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y12 inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y12 inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
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21
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Wadowski PP, Pultar J, Weikert C, Eichelberger B, Lang IM, Koppensteiner R, Panzer S, Gremmel T. Comparison of Light Transmission Aggregometry With Impedance Aggregometry in Patients on Potent P2Y12 Inhibitors. J Cardiovasc Pharmacol Ther 2020; 26:260-268. [PMID: 33107322 PMCID: PMC8010888 DOI: 10.1177/1074248420968706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since data on the agreement between light transmission aggregometry (LTA) and multiple electrode aggregometry (MEA) in patients on the more potent P2Y12 inhibitors are missing so far, we investigated if the evaluation of the responsiveness to therapy by LTA can be replaced by MEA in 160 acute coronary syndrome (ACS) patients on dual antiplatelet therapy with aspirin and prasugrel or ticagrelor (n = 80 each). Cut-off values for high on-treatment residual platelet reactivity (HRPR) in response to adenosine diphosphate (ADP) or arachidonic acid (AA) were defined according to previous studies showing an association of HRPR with the occurrence of adverse ischemic outcomes. ADP- inducible platelet aggregation was 33% and 37% (P = 0.07) by LTA and 19 AU and 20 AU (P = 0.38) by MEA in prasugrel- and ticagrelor-treated patients, respectively. AA- inducible platelet aggregation was 2% and 3% by LTA and 15 AU and 16 AU by MEA, (all P ≥ 0.3) in patients on prasugrel and ticagrelor, respectively. By LTA, HRPR ADP and HRPR AA were seen in 5%/5% and in 4%/ 13% of patients receiving prasugrel- and ticagrelor, respectively. By MEA, HRPR ADP and HRPR AA were seen in 3%/ 25% and 0%/24% of prasugrel- and ticagrelor-treated patients, respectively. ADP-inducible platelet reactivity by MEA correlated significantly with LTA ADP in prasugrel-treated patients (r = 0.4, P < 0.001), but not in those receiving ticagrelor (r = 0.09, P = 0.45). AA-inducible platelet aggregation by LTA and MEA did not correlate in prasugrel- and ticagrelor-treated patients. Sensitivity/specificity of HRPR by MEA to detect HRPR by LTA were 25%/99% for MEA ADP and 100%/79% for MEA AA in prasugrel-treated patients, and 0%/100% for MEA ADP and 70%/83% for MEA AA in ticagrelor-treated patients. In conclusion, on-treatment residual ADP-inducible platelet reactivity by LTA and MEA shows a significant correlation in prasugrel- but not ticagrelor-treated patients. However, in both groups LTA and MEA revealed heterogeneous results regarding the classification of patients as responders or non-responders to P2Y12 inhibition.
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Affiliation(s)
- Patricia P Wadowski
- Department of Internal Medicine II, 27271Medical University of Vienna, Vienna, Austria
| | - Joseph Pultar
- Department of Internal Medicine II, 27271Medical University of Vienna, Vienna, Austria
| | - Constantin Weikert
- Department of Internal Medicine II, 27271Medical University of Vienna, Vienna, Austria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion Medicine, 27271Medical University of Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, 27271Medical University of Vienna, Vienna, Austria
| | - Renate Koppensteiner
- Department of Internal Medicine II, 27271Medical University of Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, 27271Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine II, 27271Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
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22
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Kirresh A, Coghlan G, Candilio L. COVID-19 Infection and High Intracoronary Thrombus Burden. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 28:82-87. [PMID: 32967797 PMCID: PMC7390795 DOI: 10.1016/j.carrev.2020.07.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 01/27/2023]
Abstract
Coronavirus 2019 (COVID-19) is an acute respiratory disease that has rapidly spread around the world and been declared a global pandemic by the World Health Organization. Emerging evidence demonstrates a strong association with a pro-thrombotic state and we present the first patient admitted with COVID-19 and an inferior ST-segment elevation myocardial infarction (STEMI) with evidence of high intracoronary thrombus burden. We review the mechanism of the high thrombus burden, which may be driven by the significant cytokine storm, endothelial dysfunction, increase risk of coronary plaque rupture and hypercoagulability.
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Affiliation(s)
- Ali Kirresh
- Cardiology Department, Royal Free Hospital, London, United Kingdom.
| | - Gerry Coghlan
- Cardiology Department, Royal Free Hospital, London, United Kingdom
| | - Luciano Candilio
- Cardiology Department, Royal Free Hospital, London, United Kingdom
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23
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Buchtele N, Herkner H, Schörgenhofer C, Merrelaar A, Laggner R, Gelbenegger G, Spiel AO, Domanovits H, Lang I, Jilma B, Schwameis M. High Platelet Reactivity after Transition from Cangrelor to Ticagrelor in Hypothermic Cardiac Arrest Survivors with ST-Segment Elevation Myocardial Infarction. J Clin Med 2020; 9:jcm9020583. [PMID: 32098088 PMCID: PMC7073541 DOI: 10.3390/jcm9020583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 12/20/2022] Open
Abstract
Transition from cangrelor to oral P2Y12 inhibitors after PCI carries the risk of platelet function recovery and acute stent thrombosis. Whether the recommended transition regimen is appropriate for hypothermic cardiac arrest survivors is unknown. We assessed the rate of high platelet reactivity (HPR) after transition from cangrelor to ticagrelor in hypothermic cardiac arrest survivors. Adult survivors of out-of-hospital cardiac arrest with ST-segment elevation myocardial infarction (STEMI), who were treated for hypothermia (33 °C ± 1) and received intravenous cangrelor during PCI and subsequent oral loading with 180mg ticagrelor were enrolled in this prospective observational cohort study. Platelet function was assessed using whole blood aggregometry. HPR was defined as AUC > 46U. The primary endpoint was the rate of HPR (%) at predefined time points during the first 24 h after cangrelor cessation. Poisson regression was used to estimate the relationship between the overlap time of cangrelor and ticagrelor co-administration and the number of subsequent HPR episodes, expressed as incidence rate ratio (IRR) with 95% confidence interval (95%CI). Between December 2017 and October 2019 16 patients (81% male, 58 years) were enrolled. On average, ticagrelor was administered 39 min (IQR 5-50) before the end of cangrelor infusion. The rate of HPR was highest 90 min after cangrelor cessation and was present in 44% (7/16) of patients. The number of HPR episodes increased significantly with decreasing overlap time of cangrelor and ticagrelor co-administration (IRR 1.03, 95%CI 1.01-1.05; p = 0.005). In this selected cohort of hypothermic cardiac arrest survivors who received cangrelor during PCI, ticagrelor loading within the recommended time frame before cangrelor cessation resulted in a substantial amount of patients with HPR.
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Affiliation(s)
- Nina Buchtele
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
- Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
| | - Christian Schörgenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
| | - Anne Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
| | - Roberta Laggner
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
| | - Alexander O. Spiel
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
- Correspondence: ; Tel.: +43-1-40-400-39560
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
| | - Irene Lang
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria; (N.B.); (C.S.); (G.G.); (B.J.)
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (H.H.); (A.M.); (H.D.); (M.S.)
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24
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Gerbaud E, Elbaz M, Lattuca B. New insights into cardiogenic shock and coronary revascularization after acute myocardial infarction. Arch Cardiovasc Dis 2020; 113:276-284. [PMID: 32088156 DOI: 10.1016/j.acvd.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
Cardiogenic shock complicating acute myocardial infarction is challenging, and continues to be associated with high rates of in-hospital and long-term mortality. Coronary revascularization is critical for improving prognosis in CS. Thus, a systematic protocol-driven approach to cardiogenic shock, the development of specialized cardiac care centres, technical advances in interventional cardiology enabling treatment of more complex and severe lesions, the availability of recent antithrombotic therapies and the evolution of new haemodynamic support devices are important considerations in current management of cardiogenic shock complicating acute ischaemic heart disease. Despite these potentially meaningful developments, several substantial gaps in knowledge still exist regarding optimal coronary revascularization of patients with cardiogenic shock. This review will describe current principles in the revascularization of these patients, with a focus on: the time to transfer and revascularize; the choice of vascular access site; the need for complete revascularization or only a culprit lesion strategy; the optimal antithrombotic therapy; the type, place and timing of haemodynamic support; and the medical care system network.
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Affiliation(s)
- Edouard Gerbaud
- Cardiology Intensive Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, 33600 Pessac, France; Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, 33000 Bordeaux, France
| | - Meyer Elbaz
- Department of Cardiology, CARDIOMET Institute, Rangueil Medical School, University Paul Sabatier, 31059 Toulouse, France.
| | - Benoit Lattuca
- Cardiology Department, Caremeau University Hospital, ACTION Study Group, Montpellier University, 30029 Nîmes, France
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25
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Abstract
Inadequate antiplatelet effects can result in substantial morbidity and mortality in patients with acute coronary syndrome and percutaneous coronary intervention (PCI). Cangrelor is a rapid onset and potent intravenous P2Y12 inhibitor that has been shown in large randomized controlled trials to reduce periprocedural complications for PCI compared with clopidogrel, the most commonly used P2Y12 inhibitor. Cangrelor should be considered in the setting of PCI to reduce the risk of periprocedural complications such as myocardial infarction, repeat coronary revascularization and stent thrombosis in patients not yet treated with another P2Y12 inhibitor or glycoprotein IIb/IIIa inhibitor. In this review, the importance of adequate P2Y12 inhibition, cangrelor's pharmacology and clinical profiles, and future directions for the cangrelor are discussed.
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Affiliation(s)
- Kent Y Feng
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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26
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Gorog DA, Price S, Sibbing D, Baumbach A, Capodanno D, Gigante B, Halvorsen S, Huber K, Lettino M, Leonardi S, Morais J, Rubboli A, Siller-Matula JM, Storey RF, Vranckx P, Rocca B. Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:125-140. [PMID: 32049278 DOI: 10.1093/ehjcvp/pvaa009] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/10/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
Timely and effective antithrombotic therapy is critical to improving outcome, including survival, in patients with acute coronary syndrome (ACS). Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.
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Affiliation(s)
- Diana A Gorog
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Susanna Price
- Department of Medicine, National Heart & Lung Institute, Imperial College, London, UK.,Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Dirk Sibbing
- Ludwig-Maximilians-Universität, München, Medizinische Klinik und Poliklinik I, Campus Großhadern, München, Germany
| | - Andreas Baumbach
- Barts Heart Centre, William Harvey Research Institute, Bartshealth NHS Trust, Queen Mary University of London, West Smithfield, London, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Bruna Gigante
- Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science, Danderyds Hospital, Danderyd, Sweden
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical School, Vienna, Austria
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Sergio Leonardi
- Coronary Care Unit, University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Joao Morais
- Cardiology Division, Leiria Hospital Center, Pousos, Leiria, Portugal.,ciTechCare, Polytechnic of Leiria, Leiria, Portugal
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
| | | | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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27
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Pareek N, Kordis P, Webb I, Noc M, MacCarthy P, Byrne J. Contemporary Management of Out-of-hospital Cardiac Arrest in the Cardiac Catheterisation Laboratory: Current Status and Future Directions. Interv Cardiol 2019; 14:113-123. [PMID: 31867056 PMCID: PMC6918505 DOI: 10.15420/icr.2019.3.2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is an important cause of mortality and morbidity in developed countries and remains an important public health burden. A primary cardiac aetiology is common in OHCA patients, and so patients are increasingly brought to specialist cardiac centres for consideration of coronary angiography, percutaneous coronary intervention and mechanical circulatory support. This article focuses on the management of OHCA in the cardiac catheterisation laboratory. In particular, it addresses conveyance of the OHCA patient direct to a specialist centre, the role of targeted temperature management, pharmacological considerations, provision of early coronary angiography and mechanical circulatory support.
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Affiliation(s)
- Nilesh Pareek
- King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
| | | | - Ian Webb
- King’s College Hospital NHS Foundation TrustLondon, UK
| | - Marko Noc
- University Medical CentreLjubljana, Slovenia
| | - Philip MacCarthy
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation TrustLondon, UK
- School of Cardiovascular Medicine & Sciences, BHF Centre of ExcellenceKing’s College London, UK
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28
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Marquis‐Gravel G, Zeitouni M, Kochar A, Jones WS, Sketch MH, Rao SV, Patel MR, Ohman EM. Technical consideration in acute myocardial infarction with cardiogenic shock: A review of antithrombotic and PCI therapies. Catheter Cardiovasc Interv 2019; 95:924-931. [DOI: 10.1002/ccd.28455] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 07/15/2019] [Accepted: 08/06/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Guillaume Marquis‐Gravel
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | | | - Ajar Kochar
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - W. Schuyler Jones
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - Michael H. Sketch
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - Sunil V. Rao
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
| | - E. Magnus Ohman
- Duke Clinical Research Institute Durham North Carolina
- Division of CardiologyDuke University Medical Center Duke Heart Center, Durham North Carolina
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29
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Eyileten C, Soplinska A, Pordzik J, Siller‐Matula JM, Postuła M. Effectiveness of Antiplatelet Drugs Under Therapeutic Hypothermia: A Comprehensive Review. Clin Pharmacol Ther 2019; 106:993-1005. [DOI: 10.1002/cpt.1492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Ceren Eyileten
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Aleksandra Soplinska
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Justyna Pordzik
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | | | - Marek Postuła
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
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30
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Knoop B, Naguib D, Dannenberg L, Helten C, Zako S, Jung C, Levkau B, Grandoch M, Kelm M, Zeus T, Polzin A. Cardioprotection by very mild hypothermia in mice. Cardiovasc Diagn Ther 2019; 9:64-67. [PMID: 30881880 DOI: 10.21037/cdt.2018.08.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Target temperature management is recommended in post-resuscitation care. Additionally, hypothermia is a promising option in adjunctive therapy of acute myocardial infarction (MI). However, first in men data are contradicting. There are still many open questions to identify the optimal regimen and target temperature. In this study, we aimed to investigate the effect of very mild hypothermia on infarct size (IS) in mice. Mice underwent cardiac ischemia by temporary occlusion of the left anterior descending (LAD) artery under conditions of very mild hypothermia (34-36 °C). Hypothermia was reached within the first 5 minutes of ischemia (temperature: 34.6±0.5 vs. 36.8±1.1 °C, P=0.035). Very mild hypothermia reduced IS in mice undergoing 30 minutes ischemia [IS/area at risk (AAR): 45±12% vs. 22±4%, P=0.018] as well as mice undergoing 60 minutes ischemia [IS/AAR: 67±7% vs. 28±2%, P=0.0003]. Very mild hypothermia reduces IS. This new approach in adjunctive therapy of patients with acute MI should be investigated in clinical trials.
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Affiliation(s)
- Betül Knoop
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - David Naguib
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Lisa Dannenberg
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Carolin Helten
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Saif Zako
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Bodo Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Maria Grandoch
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
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31
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Umińska JM, Ratajczak J, Buszko K, Sobczak P, Sroka W, Marszałł MP, Adamski P, Steblovnik K, Noč M, Kubica J. Impact of mild therapeutic hypothermia on bioavailability of ticagrelor in patients with acute myocardial infarction after out-of-hospital cardiac arrest. Cardiol J 2019; 27:780-788. [PMID: 30799546 DOI: 10.5603/cj.a2019.0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) frequently occurs in the early phase of acute myocardial infarction (MI). Survivors require percutaneous coronary intervention (PCI) with concomitant dual antiplatelet therapy. Target temperature management, including mild therapeutic hypothermia (MTH), should be applied in comatose patients after resuscitation. However, an increased risk of stent thrombosis in patients undergoing hypothermia is observed. The aim of this study was to assess the impact of MTH on pharmacokinetics of ticagrelor in cardiac arrest survivors with MI treated with MTH and PCI. METHODS In a prospective, observational, single-center study pharmacokinetics of ticagrelor were evaluated in 41 MI patients, including 11 patients after OHCA undergoing MTH (MTH group) and 30 MI patients without OHCA and MTH (no-MTH group). Blood samples were drawn before administration of a 180 mg ticagrelor loading dose, and 30 min, 1, 2, 4, 6, 12, and 24 h after the loading dose. RESULTS In patients treated with MTH total exposure to ticagrelor during the first 12 h after the loading dose and maximal plasma concentration of ticagrelor were significantly lower than in the no-MTH group (AUC(0-12): 3403 ± 2879 vs. 8746 ± 5596 ng·h/mL, difference: 61%, p = 0.01; Cmax: 475 ± 353 vs. 1568 ± 784 ng/mL, p = 0.0002). Time to achieve maximal ticagrelor plasma concentration was also delayed in the MTH group (tmax for ticagrelor: 12 [6-24] vs. 4 [2-12] h, p = 0.01). CONCLUSIONS Bioavailability of ticagrelor was substantially decreased and delayed in MI patients treated with MTH after OHCA. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02611934.
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Affiliation(s)
- Julia M Umińska
- Department of Geriatric, Collegium Medicum, Nicolaus Copernicus University, Ul. M.Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland.
| | - Jakub Ratajczak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Katarzyna Buszko
- Department of Theoretical Foundations of Biomedical Science and Medical Informatics, Collegium Medicum, Nicolaus Copernicus University, ul. Jagiellońska 13-15,, 85-067 Bydgoszcz, Poland
| | - Przemysław Sobczak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Wiktor Sroka
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Ul. M.Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Michał P Marszałł
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Ul. M.Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Klemen Steblovnik
- Ljubljana University Medical Centre, University of Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
| | - Marko Noč
- Ljubljana University Medical Centre, University of Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
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32
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Cangrelor in cardiogenic shock and after cardiopulmonary resuscitation: A global, multicenter, matched pair analysis with oral P2Y 12 inhibition from the IABP-SHOCK II trial. Resuscitation 2019; 137:205-212. [PMID: 30790690 DOI: 10.1016/j.resuscitation.2019.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 01/06/2023]
Abstract
AIMS Cangrelor has a potentially favorable pharmacodynamic profile in cardiogenic shock (CS). We aimed to evaluate the clinical course of CS patients undergoing percutaneous coronary intervention (PCI) treated with cangrelor. METHODS AND RESULTS We retrospectively identified 136 CS patients treated with cangrelor. Patients were 1:1 matched to CS patients from the IABP-SHOCK II trial not receiving cangrelor by age, sex, cardiac arrest, type of myocardial infarction, culprit lesion, glycoprotein IIb/IIIa inhibitor, and oral P2Y12-receptor inhibitor and followed-up for 12 months. The study cohort consisted of 88 matched pairs. Thirty-day and 12-month mortality was 29.5% and 34.1% in cangrelor-treated patients and 36.4% and 47.1% in control group (P = 0.34 and P = 0.08, respectively). The rate of definite acute stent thrombosis was 2.3% in both groups. Moderate and severe bleeding events occurred in 21.6% in the cangrelor and 19.3% in the control group (P = 0.71). Patients treated with cangrelor more frequently experienced ≥1 TIMI flow grade improvement during PCI (92.9% vs. 81.2%, P = 0.02). CONCLUSION Cangrelor treatment was associated with similar bleeding risk and significantly better TIMI flow improvement compared with oral P2Y12 inhibitors in CS patients undergoing PCI. The use of cangrelor in CS offers a potentially safe and effective antiplatelet option and should be evaluated in randomized trials.
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33
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Kim WY. Crushed Prasugrel Tablets in Patients With STEMI Undergoing Primary Percutaneous Coronary Intervention: The CRUSH Study. J Am Coll Cardiol 2019; 69:249-250. [PMID: 28081836 DOI: 10.1016/j.jacc.2016.08.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 08/16/2016] [Accepted: 08/23/2016] [Indexed: 11/28/2022]
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34
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Capodanno D, Milluzzo RP, Angiolillo DJ. Intravenous antiplatelet therapies (glycoprotein IIb/IIIa receptor inhibitors and cangrelor) in percutaneous coronary intervention: from pharmacology to indications for clinical use. Ther Adv Cardiovasc Dis 2019; 13:1753944719893274. [PMID: 31823688 PMCID: PMC6906352 DOI: 10.1177/1753944719893274] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 08/16/2019] [Indexed: 12/20/2022] Open
Abstract
Oral antiplatelet drugs are crucially important for patients with acute coronary syndrome or stable coronary artery disease undergoing percutaneous coronary intervention (PCI). In recent decades, several clinical trials have focused on reducing periprocedural ischemic events in patients undergoing PCI by means of more rapid platelet inhibition with the use of intravenous antiplatelet drugs. Glycoprotein IIb/IIIa receptor inhibitors (GPIs) block the final common pathway of platelet aggregation and enable potent inhibition in the peri-PCI period. In recent years, however, the use of GPIs has decreased due to bleeding concerns and the availability of more potent oral P2Y12 inhibitors. Cangrelor is an intravenous P2Y12 receptor antagonist. In a large-scale regulatory trial, cangrelor administration during PCI allowed for rapid, potent and rapidly reversible inhibition of platelet aggregation, with an anti-ischemic benefit and no increase in major bleeding. This article aims to provide an overview of general pharmacology, supporting evidence and current status of intravenous antiplatelet therapies (GPIs and cangrelor), with a focus on contemporary indications for their clinical use.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U.
‘Policlinico-Vittorio Emanuele’, University of Catania, P.O. Rodolico, Ed.
8, Via Santa Sofia 78, 95123 Catania, Sicilia, Italy
| | - Rocco P. Milluzzo
- Division of Cardiology, A.O.U.
‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Sicilia,
Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine,
University of Florida College of Medicine, Jacksonville, FL, USA
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35
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Cangrelor Induces More Potent Platelet Inhibition without Increasing Bleeding in Resuscitated Patients. J Clin Med 2018; 7:jcm7110442. [PMID: 30445678 PMCID: PMC6262477 DOI: 10.3390/jcm7110442] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 12/31/2022] Open
Abstract
Dual antiplatelet therapy is the standard of care for patients with myocardial infarction (MI), who have been resuscitated and treated with therapeutic hypothermia (TH). We compare the antiplatelet effect and bleeding risk of intravenous cangrelor to oral P2Y12-inhibitors in patients with MI receiving TH in a prospective comparison of two matched patient cohorts. Twenty-five patients within the CANGRELOR cohort were compared to 17 patients receiving oral P2Y12-inhibitors. CANGRELOR group (NCT03445546) and the ORAL P2Y12 Group (NCT02914795) were registered at clinicaltrials.gov. Platelet function testing was performed using light-transmittance aggregometry and monitored for 4 days. P2Y12-inhibition was stronger in CANGRELOR compared to ORAL P2Y12 (adenosine diphosphate (ADP) (area under the curve (AUC)) 26.0 (5.9–71.6) vs. 160.9 (47.1–193.7)) at day 1. This difference decreased over the following days as more patients were switched from CANGRELOR to oral P2Y12-inhibitor treatment. There was no difference in the effect of aspirin between the two groups. We did not observe significant differences with respect to thrombolysis in myocardial infarction (TIMI) or Bleeding Academic Research Consortium (BARC) classified bleedings, number of blood transfusions or drop in haemoglobin B (Hb) or hematocrit (Hct) over time. Cangrelor treatment is not only feasible and effective in resuscitated patients, but also inhibited platelet function more effectively than orally administered P2Y12-inhibitors without an increased event rate for bleeding.
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36
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Testori C, Beitzke D, Mangold A, Sterz F, Loewe C, Weiser C, Scherz T, Herkner H, Lang I. Out-of-hospital initiation of hypothermia in ST-segment elevation myocardial infarction: a randomised trial. Heart 2018; 105:531-537. [PMID: 30361270 PMCID: PMC6580740 DOI: 10.1136/heartjnl-2018-313705] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/15/2018] [Accepted: 09/19/2018] [Indexed: 01/29/2023] Open
Abstract
Objective To evaluate the effect of prereperfusion hypothermia initiated in the out-of-hospital setting in awake patients with ST-segment elevation myocardial infarction (STEMI) on myocardial salvage measured by cardiac MRI (CMR). Methods Hypothermia was initiated within 6 hours of symptom onset by the emergency medical service with surface cooling pads and cold saline, and continued in the cath lab with endovascular cooling (target temperature: ≤35°C at time of reperfusion). Myocardial salvage index (using CMR) was compared in a randomised, controlled, open-label, endpoint blinded trial to a not-cooled group of patients at day 4±2 after the event. Results After postrandomisation exclusion of 19 patients a total of 101 patients were included in the intention-to-treat analysis (control group: n=54; hypothermia group: n=47). Target temperature was reached in 38/47 patients (81%) in the intervention group. Study-related interventions resulted in a delay in time from first medical contact to reperfusion of 14 min (control group 89±24 min; hypothermia group 103±21 min; p<0.01). Myocardial salvage index was 0.37 (±0.26) in the control group and 0.43 (±0.27) in the hypothermia group (p=0.27). No differences in cardiac biomarkers or clinical outcomes were found. In a CMR follow-up 6 months after the initial event no significant differences were detected. Conclusion Out-of-hospital induced therapeutic hypothermia as an adjunct to primary percutaneous coronary intervention did not improve myocardial salvage in patients with STEMI. Trial registration number NCT01777750
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Affiliation(s)
- Christoph Testori
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Dietrich Beitzke
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Andreas Mangold
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christoph Weiser
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Scherz
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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37
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Fiore M, Gerbaud E, Coste P, Cetran L, Marchand H, Seguy B. Optimal platelet inhibition with cangrelor in comatose survivors of out-of-hospital cardiac arrest undergoing primary percutaneous coronary intervention. Resuscitation 2018; 130:e1-e2. [PMID: 29969644 DOI: 10.1016/j.resuscitation.2018.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 06/19/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Mathieu Fiore
- Laboratory of Hematology, Reference Center for Platelet Disorders, University Hospital of Bordeaux, Pessac, France.
| | - Edouard Gerbaud
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Pierre Coste
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Laura Cetran
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Hugo Marchand
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
| | - Benjamin Seguy
- Cardiovascular Intensive Care Unit, Cardiologic Hospital, University Hospital of Bordeaux, Pessac, France
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38
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Wester A, Mohammad MA, Andell P, Rylance R, Dankiewicz J, Friberg H, James S, Omerovic E, Erlinge D, Koul S. Coronary angiographic findings and outcomes in patients with sudden cardiac arrest without ST-elevation myocardial infarction: A SWEDEHEART study. Resuscitation 2018; 126:172-178. [DOI: 10.1016/j.resuscitation.2018.01.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/16/2018] [Accepted: 01/29/2018] [Indexed: 01/23/2023]
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Abstract
The prognosis after out-of-hospital cardiac arrest (OHCA) has improved in the past few decades because of advances in interventions used outside and in hospital. About half of patients who have OHCA with initial ventricular tachycardia or ventricular fibrillation and who are admitted to hospital in coma after return of spontaneous circulation will survive to discharge with a reasonable neurological status. In this Series paper we discuss in-hospital management of patients with post-cardiac-arrest syndrome. In most patients, the most important in-hospital interventions other than routine intensive care are continuous active treatment (in non-comatose and comatose patients and including circulatory support in selected patients), cooling of core temperature to 32-36°C by targeted temperature management for at least 24 h, immediate coronary angiography with or without percutaneous coronary intervention, and delay of final prognosis until at least 72 h after OHCA. Prognosis should be based on clinical observations and multimodal testing, with focus on no residual sedation.
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Affiliation(s)
- Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Ken Nagao
- Cardiovascular Centre, Nihon University Hospital, Tokyo, Japan
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton and Hove, UK
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40
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Prüller F, Milke OL, Bis L, Fruhwald F, Scherr D, Eller P, Pätzold S, Altmanninger-Sock S, Rainer P, Siller-Matula J, von Lewinski D. Impaired aspirin-mediated platelet function inhibition in resuscitated patients with acute myocardial infarction treated with therapeutic hypothermia: a prospective, observational, non-randomized single-centre study. Ann Intensive Care 2018; 8:28. [PMID: 29468430 PMCID: PMC5821616 DOI: 10.1186/s13613-018-0366-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 02/01/2018] [Indexed: 12/20/2022] Open
Abstract
The majority of resuscitated patients present with underlying cardiac disease, and out of these myocardial infarction is most common. Immediate interventional treatment is recommended and routinely requires dual antiplatelet therapy including aspirin and a P2Y12-inhibitor. Therapeutic hypothermia or target temperature management is also recommended in these patients. Cardiogenic shock as well as reduced body temperature impacts platelet reactivity and its medical inhibition. The study aims to quantify aspirin- and P2Y12-mediated platelet inhibition in patients presenting with myocardial infarction and cardiopulmonary resuscitation. Twenty-five resuscitated patients were enrolled in this prospective, observational, non-randomized single-centre study. These patients were compared to 77 matched controls from the ATLANTIS-ACS database of non-resuscitated patients with myocardial infarction. Platelet function testing was performed by light transmittance aggregometry. Aspirin reactivity was monitored by inducing platelet aggregation with collagen and arachidonic acid, respectively. P2Y12 inhibition was recorded by stimulation of platelet aggregation with adenosine diphosphate. To quantify the overall platelet response, thrombin receptor-activated peptide was used. Aspirin-mediated platelet reactivity decreased significantly in resuscitated patients during the first days and was significantly weaker on day 3 (collagen AUC 253.8 (122.7–352.2) vs. 109.0 (73.0–182.0); p = 0.022). P2Y12-mediated platelet inhibition was also impaired in resuscitated patients on day 3 (mean ADP AUC (IQR): CPR 172.1 (46.7−346.5) vs. control 43.9 (18.9–115.2); p < 0.05). Aspirin- and P2Y12-mediated platelet inhibition is impaired in resuscitated patients treated with therapeutic hypothermia. On day 3, we recorded lowest inhibitory effects of both drug types and patients might be at particular risk at that time. Potentially, intravenous aspirin and P2Y12 inhibitors might still supply a more predictable and stable platelet inhibition.
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Affiliation(s)
- Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, Graz, Austria
| | | | - Lukasz Bis
- Medical University of Graz, Graz, Austria
| | - Friedrich Fruhwald
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Daniel Scherr
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, University Hospital Graz, Graz, Austria
| | - Sascha Pätzold
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Siegfried Altmanninger-Sock
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Peter Rainer
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | | | - Dirk von Lewinski
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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Chaudhary R, Garg J, Krishnamoorthy P, Bliden K, Shah N, Agarwal N, Gupta R, Sharma A, Kern KB, Patel NC, Gurbel P. Erythropoietin therapy after out-of-hospital cardiac arrest: A systematic review and meta-analysis. World J Cardiol 2017; 9:830-837. [PMID: 29317989 PMCID: PMC5746625 DOI: 10.4330/wjc.v9.i12.830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/28/2017] [Accepted: 11/22/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess safety and efficacy of early erythropoietin (Epo) administration in patients with out-of-hospital cardiac arrest (OHCA).
METHODS A systematic literature search was performed using PubMed, MEDLINE, EMBASE, EBSCO, CINAHL, Web of Science and Cochrane databases, of all studies published from the inception through October 10, 2016. Inclusion criteria included: (1) Adult humans with OHCA and successful sustained return of spontaneous circulation; and (2) studies including mortality/brain death, acute thrombotic events as their end points. Primary efficacy outcome was “brain death or Cerebral Performance Category (CPC) score of 5”. Secondary outcomes were “CPC score 1, and 2-4”, “overall thrombotic events” and “acute coronary stent thrombosis”.
RESULTS We analyzed a total of 606 participants (n = 276 received Epo and n = 330 with standard of care alone) who experienced OHCA enrolled in 3 clinical trials. No significant difference was observed between the Epo and no Epo group in brain death or CPC score 5 (OR = 0.77; 95%CI: 0.42-1.39), CPC score 1 (OR = 1.16, 95%CI: 0.82-1.64), and CPC score 2-4 (OR = 0.77, 95%CI: 0.44-1.36). Epo group was associated with increased thrombotic complications (OR = 2.41, 95%CI: 1.26-4.62) and acute coronary stent thrombosis (OR = 8.16, 95%CI: 1.39-47.99). No publication bias was observed.
CONCLUSION Our study demonstrates no improvement in neurological outcomes and increased incidence of thrombotic events and acute coronary stent thrombosis in OHCA patients who were treated with Epo in addition to standard therapy.
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Affiliation(s)
- Rahul Chaudhary
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, MD 21215, United States
| | - Jalaj Garg
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA 18103, United States
| | - Parasuram Krishnamoorthy
- Department of Medicine, Division of Cardiology, Einstein Healthcare Network, Philadelphia, PA 19141, United States
| | - Kevin Bliden
- Inova Heart and Vascular Institute, Inova Medical Center, Fairfax, VA 22042, United States
| | - Neeraj Shah
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA 18103, United States
| | - Nayan Agarwal
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL 32611, United States
| | - Rahul Gupta
- Queens Cardiac Care, Queens, NY 11428, United States
| | - Abhishek Sharma
- Division of Cardiovascular Medicine, State University of New York, Brooklyn, NY 12246, United States
| | - Karl B Kern
- Division of Cardiology, University of Arizona College of Medicine, Tucson, AZ 85721, United States
| | - Nainesh C Patel
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA 18103, United States
| | - Paul Gurbel
- Inova Heart and Vascular Institute, Inova Medical Center, Fairfax, VA 22042, United States
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Morath T, Bernlochner I, Hadamitzky M, Braun S, Schulz S, Hoppmann P, Hausleiter J, Tiroch K, Mehilli J, Schunkert H, Massberg S, Laugwitz KL, Orban M, Mayer K, Sibbing D, Kastrati A. Prasugrel vs clopidogrel in cardiogenic shock patients undergoing primary PCI for acute myocardial infarction. Thromb Haemost 2017; 112:1190-7. [DOI: 10.1160/th14-06-0489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 07/05/2014] [Indexed: 11/05/2022]
Abstract
SummaryThere is limited clinical data comparing different P2Y12-receptor inhibitors in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock. The aim of the ISAR-SHOCK registry was to compare the clinical outcome of patients treated with clopidogrel vs prasugrel in this setting. Patients (n=145) with AMI complicated by cardiogenic shock and undergoing primary PCI in two centres (Deutsches Herzzentrum München and Klinikum rechts der Isar, Technical University Munich) between January 2009 and May 2012 were included in this registry. The use of prasugrel for patients within this registry reflected co-morbidities and platelet function testing results during the acute AMI phase. Early outcome at 30-days was reported with regard to all-cause mortality, myocardial infarction (MI), stent thrombosis (ST) and bleeding events. With regard to antiplatelet treatment in the 145 cardiogenic shock patients, 50 patients were initially treated or immediately switched to prasugrel while 95 patients were treated with clopidogrel. All-cause mortality was lower in prasugrelvs clopidogrel-treated patients (30 % vs 50.5%, HR: 0.51, 95% CI [0.29–0.92], p=0.025). No significant differences in prasugrel- vs clopidogrel-treated patients were observed for the occurrence of MI (p=0.233), ST (p=0.306) or TIMI major bleedings (p=0.571). Results of the ISAR-SHOCK registry suggest that the use of prasugrel in AMI patients complicated by cardiogenic shock might be associated with a lower mortality risk as compared to clopidogrel therapy without increasing the risk of bleeding. These findings, however, need confirmation from specifically designed randomised studies in this high-risk cohort of patients.
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Shah N, Chaudhary R, Mehta K, Agarwal V, Garg J, Freudenberger R, Jacobs L, Cox D, Kern KB, Patel N. Therapeutic Hypothermia and Stent Thrombosis: A Nationwide Analysis. JACC Cardiovasc Interv 2017; 9:1801-11. [PMID: 27609254 DOI: 10.1016/j.jcin.2016.06.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/02/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study sought to determine whether "real-world" data supported the hypothesis that therapeutic hypothermia (TH) led to increased rates of stent thrombosis. BACKGROUND TH, which is often instituted after cardiac arrest (CA) to improve neurologic outcomes, alters pharmacokinetics of antiplatelet medications, leading to a theoretical risk of stent thrombosis after percutaneous coronary intervention (PCI). METHODS CA patients with acute myocardial infarction undergoing PCI were identified from the Nationwide Inpatient Sample from 2006 to 2011, with a defined primary outcome of stent thrombosis. The incidence of stent thrombosis in patients undergoing TH versus those not undergoing TH was compared using both logistic regression and propensity score matching. RESULTS In this dataset, 49,109 CA patients underwent PCI for acute myocardial infarction from 2006 to 2011, of whom 1,193 (2.4%) underwent TH. The incidence of stent thrombosis in the TH group was 3.9% (43 of 1,193), compared to 4.7% (2,271 of 47,916) in the no TH group (p = 0.61). Logistic regression showed that TH was not a significant predictor of stent thrombosis with an adjusted odds ratio of 0.71 (95% confidence interval: 0.28 to 1.76; p = 0.46). Propensity matching was performed to adjust for baseline differences between the TH and no TH groups, matching 1,155 patients in the TH group with 3,399 patients in the no TH group. No difference was observed in the incidence of stent thrombosis in the TH and the no TH groups after propensity matching (3.5% vs. 6.1%; p = 0.17). CONCLUSIONS TH does not increase the incidence of stent thrombosis after primary PCI in patients with acute myocardial infarction presenting as CA.
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Affiliation(s)
- Neeraj Shah
- Lehigh Valley Health Network, Allentown, Pennsylvania.
| | - Rahul Chaudhary
- Johns Hopkins University/Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Kathan Mehta
- University of Pittsburgh Medical Center at Shadyside, Pittsburgh, Pennsylvania
| | | | - Jalaj Garg
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | - Larry Jacobs
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - David Cox
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Karl B Kern
- University of Arizona College of Medicine, Tucson, Arizona
| | - Nainesh Patel
- Lehigh Valley Health Network, Allentown, Pennsylvania
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Abtan J, Steg PG, Stone GW, Mahaffey KW, Gibson CM, Hamm CW, Price MJ, Abnousi F, Prats J, Deliargyris EN, White HD, Harrington RA, Bhatt DL. Efficacy and Safety of Cangrelor in Preventing Periprocedural Complications in Patients With Stable Angina and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: The CHAMPION PHOENIX Trial. JACC Cardiovasc Interv 2017; 9:1905-13. [PMID: 27659566 DOI: 10.1016/j.jcin.2016.06.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 06/19/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the safety and efficacy of cangrelor in patients with stable angina (SA) or acute coronary syndrome (ACS). BACKGROUND The CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) trial demonstrated that cangrelor significantly reduced periprocedural ischemic events in all-comer percutaneous coronary intervention with a modest increase in mild and moderate bleeding. Whether this benefit is consistent across SA and ACS has not been explored fully. METHODS The CHAMPION PHOENIX trial compared periprocedural administration of cangrelor or clopidogrel, with either a 300- or 600-mg loading dose for the prevention of periprocedural complications in patients undergoing percutaneous coronary intervention. Among the 10,942 patients in the modified intention to treat population, 6,358 patients were classified as having SA, and 4,584 patients had ACS (including unstable angina, non ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction) at randomization. The primary composite endpoint was death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h. A key secondary endpoint was stent thrombosis, and the primary safety endpoint was GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) severe bleeding. RESULTS Cangrelor consistently reduced the primary endpoint in SA and ACS (odds ratio [OR]: 0.83 [95% confidence interval (CI): 0.67 to 1.01] and OR: 0.71 [95% CI: 0.52 to 0.96], respectively; interaction p = 0.41). Cangrelor also consistently reduced stent thrombosis in SA and ACS (OR: 0.55 [95% CI: 0.30 to 1.01] and OR: 0.67 [95% CI: 0.42 to 1.06], respectively; interaction p = 0.62). The impact of cangrelor on GUSTO severe/moderate bleeding was also similar for SA and ACS (OR: 1.49 [95% CI: 0.67 to 3.33] and OR: 1.79 [95% CI: 0.79 to 4.07], respectively; interaction p = 0.75). CONCLUSIONS The benefits and risks of cangrelor were consistent in patients with SA and ACS. (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]; NCT01156571).
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Affiliation(s)
- Jérémie Abtan
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France
| | - P Gabriel Steg
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France; NLHI, ICMS, Royal Brompton Hospital, Imperial College, London, United Kingdom.
| | - Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR); Department of Medicine; Stanford School of Medicine, Stanford, California
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | | | - Matthew J Price
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California
| | - Freddy Abnousi
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California
| | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey
| | | | - Harvey D White
- University of Auckland, Auckland City Hospital, Auckland, New Zealand
| | - Robert A Harrington
- Stanford Center for Clinical Research (SCCR); Department of Medicine; Stanford School of Medicine, Stanford, California
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
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Schoergenhofer C, Hobl EL, Staudinger T, Speidl WS, Heinz G, Siller-Matula J, Zauner C, Reiter B, Kubica J, Jilma B. Prasugrel in critically ill patients. Thromb Haemost 2017; 117:1582-1587. [PMID: 28692105 PMCID: PMC6292180 DOI: 10.1160/th17-03-0154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 12/16/2022]
Abstract
While prasugrel is indicated for the treatment of myocardial infarction, its effects in the most severely affected patients requiring intensive care is unknown, so that we measured the antiplatelet effects and sparse pharmacokinetics of prasugrel in critically ill patients. Twenty-three patients admitted to medical intensive care units, who were treated with 10 mg prasugrel once daily, were included in this prospective trial. Critically ill patients responded poorly to daily prasugrel treatment: adenosine diphosphate (ADP)-induced aggregation in whole blood classified 65 % (95 % confidence intervals (CI) 43-84 %) of patients as having high on treatment platelet reactivity, platelet function under high shear rates even 74 % (95 %CI 52-90 %). There was only limited additional inhibition provided 2 hours after the next dose of prasugrel. In contrast, insufficient inhibition of the target was only seen in 26 % (95 %CI 10-48 %) of patients as measured by the vasodilator-stimulated phosphoprotein phosphorylation (VASP-P) assay. Low effective plasma levels of prasugrel active metabolite were measured at trough [0.5 (quartiles 0.5-1.1) ng/ml at baseline], and 2 hours after intake [5.7 (3.8-9.8) ng/ml], but showed coefficients of variation of ~70 %. In sum, inhibition of platelet aggregation by prasugrel is not uniform but highly variable in critically ill patients, similar to clopidogrel in a general population. The pharmacokinetic measurements indicate that poor absorption/metabolism of prasugrel may partly contribute while inflammation induced heightened intrinsic platelet reactivity may also play a role.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Bernd Jilma
- Bernd Jilma, MD, Währinger Gürtel 18-20, 1090 Vienna, Austria, Tel.: +43 1 40400 29810, Fax: +43 1 40400 29980, E-mail:
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Alexopoulos D, Pappas C, Sfantou D, Lekakis J. Cangrelor in Percutaneous Coronary Intervention: Current Status and Perspectives. J Cardiovasc Pharmacol Ther 2017; 23:13-22. [PMID: 29228817 DOI: 10.1177/1074248417715004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cangrelor is an intravenously administered P2Y12 receptor antagonist with very fast, potent, and quickly reversible action. In the CHAMPION PHOENIX trial, cangrelor provided an improved anti-ischemic protection compared with clopidogrel, without increasing the risk of severe bleeding. Cangrelor is currently approved by drug regulating authorities for patients undergoing percutaneous coronary intervention (PCI) without prior treatment with a P2Y12 receptor antagonist and not receiving a glycoprotein IIb/IIIa inhibitor, while its use is endorsed with a class IIb recommendation by the European Society of Cardiology guidelines. Several subanalyses of CHAMPION PHOENIX trial have tried to elucidate the role of cangrelor in PCI, including its usefulness during a 2-hour landmark analysis, impact on intraprocedural stent thrombosis, and reduction in myocardial infarction (MI) rate. The influence of gender, geographic region, access site, and bivalirudin use on cangrelor's effects has also been reported. In patients with ST elevation MI and in clinical scenarios of disturbed absorption of oral antiplatelet agents or in need of an intravenous agent, cangrelor may surpass oral agents' drawbacks. Transitioning to an oral agent is mandatory following cangrelor infusion discontinuation, although ticagrelor may be administered earlier without any pharmacodynamic interaction. Nevertheless, the clinical role of cangrelor in conjunction with administration of prasugrel or ticagrelor remains unclear. Accruing real-life experience is expected to improve our understanding of cangrelor's role in everyday clinical practice.
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Affiliation(s)
- Dimitrios Alexopoulos
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - Christos Pappas
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - Danai Sfantou
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - John Lekakis
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
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Jiménez-Brítez G, Freixa X, Flores-Umanzor E, San Antonio R, Caixal G, Garcia J, Hernandez-Enriquez M, Andrea R, Regueiro A, Masotti M, Brugaletta S, Martin V, Sabaté M. Out-of-hospital cardiac arrest and stent thrombosis: Ticagrelor versus clopidogrel in patients with primary percutaneous coronary intervention under mild therapeutic hypothermia. Resuscitation 2017; 114:141-145. [DOI: 10.1016/j.resuscitation.2017.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/19/2017] [Accepted: 02/15/2017] [Indexed: 12/15/2022]
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Nikolaou NI. Stent thrombosis in patients undergoing coronary stenting after return of spontaneous circulation. Does the choice of antiplatelet drug matter? Resuscitation 2017; 114:A8-A9. [DOI: 10.1016/j.resuscitation.2017.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
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