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Komócsi A, Merkely B, Hadamitzky M, Massberg S, Rizas KD, Hein-Rothweiler R, Gross L, Trenk D, Sibbing D, Aradi D. Impact of body mass on P2Y12-inhibitor de-escalation in acute coronary syndromes-a substudy of the TROPICAL-ACS trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:608-616. [PMID: 37015874 PMCID: PMC10627813 DOI: 10.1093/ehjcvp/pvad027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/10/2023] [Accepted: 04/03/2023] [Indexed: 04/06/2023]
Abstract
AIMS Clinical guidelines recommend de-escalation antiplatelet strategies to reduce bleeding risk in acute coronary syndrome (ACS) patients, albeit with a weak recommendation. This substudy of the TROPICAL-ACS trial aimed to determine the impact of body mass on the efficacy of a platelet function testing-guided de-escalation regimen in ACS patients after percutaneous coronary intervention. METHODS AND RESULTS Patients were randomized to prasugrel (control group) or a platelet function testing-guided regimen with clopidogrel or prasugrel defined after 1-week clopidogrel. The primary endpoint was the net clinical benefit [cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium (BARC) 2-5 bleeding] for 12 months. Overweight was defined as a body mass index >25 kg/m2.Patients without overweight showed a significant net clinical benefit from the de-escalation strategy, while in overweight cases de-escalation was comparable to prasugrel treatment [hazard ratio (HR): 0.52; 95% confidence interval (CI): 0.31-0.88; P = 0.013 and HR: 0.95; 95% CI: 0.69-1.31, P = 0.717, P-non-inferiority = 0.03, respectively, P-interaction = 0.053]. The benefit of de-escalation in terms of the risk of bleeding or of the ischaemic events did not reach statistical significance. Bleeding events with de-escalation were less frequent in non-overweight patients but comparable in overweight patients (HR: 0.55; 95% CI: 0.30-1.03; P = 0.057 and HR: 0.95; 95% CI: 0.64-1.41, respectively, P-interaction = 0.147). Non-overweight patients had lower ischaemic event rates with de-escalation, while overweight cases had slightly less (HR: 0.47; 95% CI: 0.18-1.25; P = 0.128 and HR: 0.89; 95% CI: 0.53-1.50, respectively, P-interaction = 0.261). CONCLUSION The strategy of guided dual antiplatelet therapy de-escalation was associated with a significant net clinical benefit in non-overweight patients, while the two strategies were equivalent in overweight patients.
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Affiliation(s)
- András Komócsi
- Heart Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Lisa Gross
- Ludwig-Maximilians University, Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology–Clinical Pharmacology, Medical Center–University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | | | - Dániel Aradi
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
- Balatonfured State Cardiology Hospital, Balatonfured, Hungary
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2
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Parker WAE, Angiolillo DJ, Rollini F, Franchi F, Bonaca MP, Bhatt DL, Steg PG, Orme RC, Thomas MR, Judge HM, Sabatine MS, Storey RF. Influence of body weight and body mass index on the chronic pharmacokinetic and pharmacodynamic responses to clinically available doses of ticagrelor in patients with chronic coronary syndromes. Vascul Pharmacol 2023; 149:107145. [PMID: 36720377 DOI: 10.1016/j.vph.2023.107145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/25/2023] [Indexed: 01/30/2023]
Abstract
Ticagrelor has multiple indications, including for some patients with chronic coronary syndromes (CCS) at high risk of ischaemic events. Body mass can potentially affect pharmacodynamics (PD) and pharmacokinetics (PK). We investigated the influence of body mass (range 53-172 kg, 20.8-46.9 kg/m2) on PD/PK in 221 CCS patients receiving ticagrelor 60 mg or 90 mg twice-daily (BD) during two randomised-controlled trials. Correlations between body weight (BW) or body mass index (BMI) and PD/PK measurements obtained during maintenance treatment at trough ('pre-dose') and peak effect ('post-dose') were assessed. BW and BMI correlated with P2Y12 reactivity units at pre-dose (e.g. BW:R = 0.26, p = 0.008) but not post-dose timepoints. BW affected ticagrelor active metabolite (TAM) levels (e.g. 60 mg BD, post-dose:R = -0.39, p < 0.0001) and there was evidence of an inverse power law relationship between BW and TAM-to-ticagrelor ratio. PK with ticagrelor 60 mg correlated significantly with BMI. BW and BMI did not affect the chance of high platelet reactivity, which remained very low across the whole cohort. There was no difference in PRU between the two doses of ticagrelor within each weight or BMI group. Body mass has modest effects on the PK/PD response to ticagrelor in patients with CCS but currently-used regimens appear adequate across the range of BW/BMI studied.
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Affiliation(s)
- William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Marc P Bonaca
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ph Gabriel Steg
- Université Paris-Cité, INSERM UMR1148/LVTS, AP-HP, Hôpital Bichat, Paris, France
| | - Rachel C Orme
- Department of Cardiology, St John of God Hospital, Southwest Health Campus, Bunbury, WA, Australia
| | - Mark R Thomas
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Heather M Judge
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Marc S Sabatine
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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3
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Antithrombotic Therapies and Body Mass Index. JACC Cardiovasc Interv 2022; 15:1961-1964. [DOI: 10.1016/j.jcin.2022.08.031] [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: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 01/09/2023]
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4
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Kunadian V, Baber U, Pivato CA, Cao D, Dangas G, Sartori S, Zhang Z, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Dehghani P, Mehta S, Moliterno DJ, Ohman EM, Escaned J, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Džavík V, Gurbel P, Hamm CW, Henry T, Kastrati A, Marx SO, Oldroyd K, Steg PG, Pocock S, Mehran R. Bleeding and Ischemic Outcomes With Ticagrelor Monotherapy According to Body Mass Index. JACC Cardiovasc Interv 2022; 15:1948-1960. [DOI: 10.1016/j.jcin.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 01/09/2023]
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Lahu S, Behnes M, Ndrepepa G, Neumann FJ, Sibbing D, Bernlochner I, Menichelli M, Mayer K, Richardt G, Gewalt S, Angiolillo DJ, Coughlan JJ, Aytekin A, Witzenbichler B, Hochholzer W, Cassese S, Kufner S, Xhepa E, Sager HB, Joner M, Fusaro M, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A, Akin I. Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:747-755. [PMID: 34961732 DOI: 10.1016/j.rec.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES The efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI. METHODS Patients (n=3987) were grouped into 3 categories: normal weight (BMI <25kg/m2; n=1084), overweight (BMI ≥ 25 to <30kg/m2; n=1890), and obesity (BMI ≥ 30kg/m2; n=1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding. RESULTS The primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P=.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P=.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P=.451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P=.990), overweight (5.6% vs 5.0%; P=.566) or obesity (4.4% vs 2.8%; P=.219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=.578) or secondary endpoint (Pint=.596). CONCLUSIONS In patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety. CLINICAL TRIAL REGISTRATION NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gjin Ndrepepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Cardiology, Klinik der Universität München, Ludwig - Maximilians - University, Munich, Germany
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | | | - Katharina Mayer
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gert Richardt
- Department of Cardiology and Angiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Senta Gewalt
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - John Joseph Coughlan
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alp Aytekin
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Salvatore Cassese
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Hendrik B Sager
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Joner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Massimiliano Fusaro
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | - Heribert Schunkert
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Stefanie Schüpke
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Adnan Kastrati
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Lahu S, Behnes M, Ndrepepa G, Neumann FJ, Sibbing D, Bernlochner I, Menichelli M, Mayer K, Richardt G, Gewalt S, Angiolillo DJ, Coughlan JJ, Aytekin A, Witzenbichler B, Hochholzer W, Cassese S, Kufner S, Xhepa E, Sager HB, Joner M, Fusaro M, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A, Akin I. Índice de masa corporal y eficacia y seguridad del ticagrelor frente al prasugrel en pacientes con síndrome coronario agudo. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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7
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Schoretsanitis G, Haen E, Piacentino D, Conca A, Endres K, Hiemke C, Gründer G, Paulzen M. Effects of body weight, smoking status, and sex on plasma concentrations of once-monthly paliperidone palmitate. Expert Rev Clin Pharmacol 2021; 15:243-249. [PMID: 34918984 DOI: 10.1080/17512433.2022.2020641] [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] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Knowledge about the impact of body composition features on pharmacokinetics of newer long-acting injectable antipsychotics is limited. METHODS We analyzed steady-state plasma concentrations of paliperidone in different body mass index (BMI), age, sex, and smoking status patient subgroups treated with once-monthly paliperidone palmitate (PP1M). Paliperidone plasma concentrations and dose-adjusted-plasma concentrations (C/D) from a therapeutic drug monitoring (TDM) database of PP1M-treated patients were compared among normal BMI, overweight, and obese patients as well as between females vs. males, elderly vs. non-elderly, and smokers vs. non-smokers using non-parametric tests. RESULTS In a total of 183 PP1M-treated patients, we found highly variable paliperidone plasma concentrations between individuals but no significant effect of PP1M dose or dosing intervals (p> 0.05). C/D ratios were similar in 54 obese, 82 overweight, and 47 normal BMI patients (p> 0.05). Females had 13.7% higher C/D ratios compared to males, yet this difference was not significant (p> 0.05). No differences were found between elderly vs. non-elderly patients or for smokers vs. non-smokers (p> 0.05). CONCLUSION Our findings suggest that age, sex, smoking, or body weight may not substantially affect pharmacokinetic indices of PP1M. The high interindividual variation of plasma concentrations implies that TDM may be helpful to enhance PP1M efficacy and tolerability.
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Affiliation(s)
- Georgios Schoretsanitis
- The Zucker Hillside Hospital, Psychiatry Research, Northwell Health, Glen Oaks, New York, NY, USA and Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Daria Piacentino
- Psychiatric Service of the Health District of Bolzano, Bolzano, Italy.,Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, The National Institutes of Health, Bethesda, MD, USA
| | - Andreas Conca
- Psychiatric Service of the Health District of Bolzano, Bolzano, Italy
| | - Katharina Endres
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Paulzen
- Alexianer Hospital Aachen, Aachen, Germany and Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and Jara - Translational Brain Medicine, Aachen, Germany
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Ndrepepa G, Holdenrieder S, Bernlochner I, Kastrati A. Influence of body size on platelet response to ticagrelor and prasugrel in patients with acute coronary syndromes. Clin Res Cardiol 2021; 111:838-842. [PMID: 34850261 PMCID: PMC9242954 DOI: 10.1007/s00392-021-01976-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technical University of Munich, Lazarettstrasse 36, 80636, Munich, Germany.
| | - Stefan Holdenrieder
- Institut Für Laboratoriumsmedizin, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Isabell Bernlochner
- Medizinische Klinik Und Poliklinik Innere Medizin I, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technical University of Munich, Lazarettstrasse 36, 80636, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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Wolny R, Maehara A, Liu Y, Zhang Z, Mintz GS, Redfors B, Madhavan MV, Smits PC, von Birgelen C, Serruys PW, Mehran R, Leon MB, Stone GW. The obesity paradox revisited: body mass index and -long-term outcomes after PCI from a large pooled patient-level database. EUROINTERVENTION 2020; 15:1199-1208. [PMID: 31659983 DOI: 10.4244/eij-d-19-00467] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to evaluate the relationship between body mass index (BMI) and outcomes in patients with coronary artery disease undergoing percutaneous revascularisation. METHODS AND RESULTS In 13 randomised trials, 22,922 patients were stratified (in kg/m2) as underweight (BMI <18.5), normal weight (18.5 ≤BMI <25, used as reference), overweight (25 ≤BMI <30), and obese (Class I [30 ≤BMI <35], Class II [35 ≤BMI <40], or Class III [BMI ≥40]). The primary endpoint was all-cause death at five years. Secondary endpoints were cardiac and non-cardiac death, target (TLR) and non-target lesion revascularisation (NTLR), myocardial infarction (MI), and definite/probable stent thrombosis. Despite adjustment for multiple confounders, overweight and Class I obesity were associated with lower all-cause mortality versus normal weight (HR 0.83, 95% CI: 0.71-0.96, and HR 0.83, 95% CI: 0.69-0.96, respectively); however, non-cardiac death was the major contributor to this effect (HR 0.77, 95% CI: 0.63-0.94 for overweight). Conversely, cardiac mortality was higher in severely obese individuals (HR 1.62, 95% CI: 1.05-2.51 for Class III obesity). Obesity was associated with higher rates of NTLR (HR 1.28, 95% CI: 1.04-1.58 for Class II obesity) but not with TLR, MI and stent thrombosis. CONCLUSIONS Moderately increased BMI is associated with improved survival post PCI, mostly due to lower non-cardiac but not cardiac mortality.
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Clinical outcomes and predictive model of platelet reactivity to clopidogrel after acute ischemic vascular events. Chin Med J (Engl) 2019; 132:1053-1062. [PMID: 30896564 PMCID: PMC6595887 DOI: 10.1097/cm9.0000000000000210] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND High on-treatment platelet reactivity (HTPR) has been suggested as a risk factor for patients with ischemic vascular disease. We explored a predictive model of platelet reactivity to clopidogrel and the relationship with clinical outcomes. METHODS A total of 441 patients were included. Platelet reactivity was measured by light transmittance aggregometry after receiving dual antiplatelet therapy. HTPR was defined by the consensus cutoff of maximal platelet aggregation >46% by light transmittance aggregometry. CYP2C19 loss-of-function polymorphisms were identified by DNA microarray analysis. The data were compared by binary logistic regression to find the risk factors. The primary endpoint was major adverse clinical events (MACEs), and patients were followed for a median time of 29 months. Survival curves were constructed with Kaplan-Meier estimates and compared by log-rank tests between the patients with HTPR and non-HTPR. RESULTS The rate of HTPR was 17.2%. Logistic regression identified the following predictors of HTPR: age, therapy regimen, body mass index, diabetes history, CYP2C192, or CYP2C193 variant. The area under the curve of receiver operating characteristic for the HTPR predictive model was 0.793 (95% confidence interval: 0.738-0.848). Kaplan-Meier analysis showed that patients with HTPR had a higher incidence of MACE than those with non-HTPR (21.1% vs. 9.9%; χ = 7.572, P = 0.010). CONCLUSIONS Our results suggest that advanced age, higher body mass index, treatment with regular dual antiplatelet therapy, diabetes, and CYP2C192 or CYP2C193 carriers are significantly associated with HTPR to clopidogrel. The predictive model of HTPR has useful discrimination and good calibration and may predict long-term MACE.
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Moser BA, LaBell ES, Chigutsa E, Jakubowski JA, Small DS. Population Pharmacokinetic and Exposure-Response Analyses of Prasugrel in Pediatric Patients with Sickle Cell Anemia. Clin Pharmacokinet 2019; 57:243-254. [PMID: 28578536 DOI: 10.1007/s40262-017-0556-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVE Prasugrel, a P2Y12 adenosine diphosphate (ADP) receptor antagonist, inhibits ADP-mediated platelet activation and aggregation in patients with sickle cell anemia (SCA). We developed a population pharmacokinetic (popPK) model in pediatric patients from 2 to <18 years of age with SCA, and performed exposure-response evaluations to characterize the effects of prasugrel in a subset of these patients who weighed 19 kg or more and experienced at least two episodes of vaso-occlusive crises (VOC) in the past year. METHODS A three-compartment popPK model adapted from that used in adults with acute coronary syndrome was used to describe the relationship between plasma concentrations of prasugrel's active metabolite (Pras-AM) and time using data from phase II and III clinical studies in children. A VOC event rate model was developed from the phase III study to explore the exposure-response relationship between Pras-AM exposure and VOC, and included evaluation of covariates. RESULTS The final popPK model for children with SCA provided a reasonable fit to Pras-AM plasma concentrations over time, with estimates of apparent clearance (CL/F) (172 L/h) and apparent volume of distribution (Vd/F) (51.7 L) that were comparable to previous studies in adults. The final model included weight as a covariate on both CL/F and Vd/F, and age as a covariate on CL/F. Analyses of safety (bleeding events requiring medical intervention) and efficacy (VOC event rate) variables showed no apparent relationship to model-predicted Pras-AM exposure quartiles, and no statistically significant effects of intrinsic or extrinsic factors on the VOC event rate were identified in the VOC event rate model. The effect of post hoc exposures on the VOC event rate did not reach statistical significance. CONCLUSIONS A popPK model was developed that provided reasonable parameter estimates, goodness-of-fit diagnostics, and visual predictive checks when applied to Pras-AM plasma concentrations in pediatric patients with SCA. Post hoc exposures obtained from this model did not correlate with measures of VOC or bleeding events in this population.
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Affiliation(s)
- Brian A Moser
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA.
| | - Elizabeth S LaBell
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
| | - Emmanuel Chigutsa
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
| | - Joseph A Jakubowski
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
| | - David S Small
- Eli Lilly and Company, Lilly Corporate Center, DC 0724, Indianapolis, IN, 46285, USA
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Aradi D, Gross L, Trenk D, Geisler T, Merkely B, Kiss RG, Komócsi A, Dézsi CA, Ruzsa Z, Ungi I, Rizas KD, May AE, Mügge A, Zeiher AM, Holdt L, Huber K, Neumann FJ, Koltowski L, Huczek Z, Hadamitzky M, Massberg S, Sibbing D. Platelet reactivity and clinical outcomes in acute coronary syndrome patients treated with prasugrel and clopidogrel: a pre-specified exploratory analysis from the TROPICAL-ACS trial. Eur Heart J 2019; 40:1942-1951. [DOI: 10.1093/eurheartj/ehz202] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/31/2019] [Accepted: 04/17/2019] [Indexed: 01/18/2023] Open
Abstract
Abstract
Aims
The value of platelet function testing (PFT) in predicting clinical outcomes and guiding P2Y12-inhibitor treatment is uncertain. In a pre-specified sub-study of the TROPICAL-ACS trial, we assessed ischaemic and bleeding risks according to high platelet reactivity (HPR) and low platelet reactivity (LPR) to ADP in patients receiving uniform prasugrel vs. PFT-guided clopidogrel or prasugrel.
Methods and results
Acute coronary syndrome patients with PFT done 14 days after hospital discharge were included with prior randomization to uniform prasugrel for 12 months (control group, no treatment modification) vs. early de-escalation from prasugrel to clopidogrel and PFT-guided maintenance treatment (HPR: switch-back to prasugrel, non-HPR: clopidogrel). The composite ischaemic endpoint included cardiovascular death, myocardial infarction, or stroke, while key safety outcome was Bleeding Academic Research Consortium (BARC) 2–5 bleeding, from PFT until 12 months. We identified 2527 patients with PFT results available: 1266 were randomized to the guided and 1261 to the control group. Before treatment adjustment, HPR was more prevalent in the guided group (40% vs. 15%), while LPR was more common in control patients (27% vs. 11%). Compared to control patients without HPR on prasugrel (n = 1073), similar outcomes were observed in guided patients kept on clopidogrel [n = 755, hazard ratio (HR): 1.06 (0.57–1.95), P = 0.86] and also in patients with HPR on clopidogrel switched to prasugrel [n = 511, HR: 0.96 (0.47–1.96), P = 0.91]. In contrast, HPR on prasugrel was associated with a higher risk for ischaemic events in control patients [n = 188, HR: 2.16 (1.01–4.65), P = 0.049]. Low platelet reactivity was an independent predictor of bleeding [HR: 1.74 (1.18–2.56), P = 0.005], without interaction (Pint = 0.76) between study groups.
Conclusion
Based on this substudy of a randomized trial, selecting prasugrel or clopidogrel based on PFT resulted in similar ischaemic outcomes as uniform prasugrel therapy without HPR. Although infrequent, HPR on prasugrel was associated with increased risk of ischaemic events. Low platelet reactivity was a strong and independent predictor of bleeding both on prasugrel and clopidogrel.
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Affiliation(s)
- Dániel Aradi
- Department of Active Cardiology, Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University Budapest, 2 Gyógy Tér, Balatonfüred, Hungary
- Department of Cardiology, Heart and Vascular Centre, Semmelweis University Budapest, Budapest, Hungary
| | - Lisa Gross
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, Tübingen, Germany
| | - Béla Merkely
- Department of Cardiology, Heart and Vascular Centre, Semmelweis University Budapest, Budapest, Hungary
| | | | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, University of Pécs, Pécs, Hungary
| | - Csaba András Dézsi
- Department of Cardiology, Petz Aladár County Hospital Győr, Győr, Hungary
| | - Zoltán Ruzsa
- Department of Cardiology, Heart and Vascular Centre, Semmelweis University Budapest, Budapest, Hungary
| | - Imre Ungi
- Department of Cardiology, University of Szeged, Szeged, Hungary
| | - Konstantinos D Rizas
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
| | - Andreas E May
- Department of Cardiology, Innere Medizin I, Klinikum Memmingen, Memmingen, Germany
| | - Andreas Mügge
- Department of Cardiology, Katholisches Klinikum Bochum, St. Josef Hospital, Bochum, Germany
| | - Andreas M Zeiher
- Department of Cardiology, Universitätsklinikum Frankfurt, Frankfurt/Main, Germany
| | - Lesca Holdt
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Sigmund Freud Private University, Medical School, Wien, Austria
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Centre Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Lukasz Koltowski
- 1 Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Zenon Huczek
- 1 Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, Deutsches Herzzentrum München, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
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Xin Y, Zhao Y, Chen X, Li J, Liu Z, Cao X, Sun Y, Hu W. Derivation and Evaluation of the Ischemic Risk Model in High-Risk Chinese Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome. Clin Ther 2019; 41:754-765. [PMID: 30935669 DOI: 10.1016/j.clinthera.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 02/04/2019] [Accepted: 03/05/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Coronary artery disease is the top cause of death among the Chinese population. With the establishment of a Chinese prediction model, it is urgent to assess factors related to the prognosis of patients with acute coronary syndrome at extremely high risk. METHODS In this retrospective study, we enrolled 601 patients assessed as being of extremely high risk, according to specific criteria from the China-PAR (Prediction for Atherosclerotic Cardiovascular Disease Risk) project, and investigated various clinical parameters using Cox multivariate analysis to establish a risk nomogram. C-index and calibration curves were involved to assess the internal identification. By using the all-cause death risk model, we stratified patients by risk level and compared the effects of clopidogrel and ticagrelor on end points. FINDINGS We identified several factors, including body mass index, angiopathy, smoking status, β-blocker usage, history of myocardial infarction, total number of stents, and usage of antiplatelet agents, related to ischemic end points, all-cause death, cardiovascular events, and cardiac death. A C-index of >0.7 and the calibration curve demonstrated good concordance. In a subsequent analysis, we used the all-cause death model to stratify patients by risk level, and compared the effects of clopidogrel and ticagrelor. In the subgroup with a 2-year death rate of >50%, ticagrelor showed a positive effect (P = 0.045), but in the subgroup with a 2-year death rate of <50%, the difference between clopidogrel and ticagrelor was not significant. Considering the duration of effect of antiplatelet agents, we also compared these 2 agents at 1-year follow up, with ticagrelor showing no advantage. IMPLICATIONS We determined the probability of ischemic risk in patients at extremely high ischemic risk and developed new risk models for this specific group. Ticagrelor, compared with clopidogrel, may improve the prognosis of patients at high risk for death after 2 years.
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Affiliation(s)
- Yanguo Xin
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China; Department of Cardiology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yinan Zhao
- Department of Neurology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Xin Chen
- Department of Cardiology, Fuling Central Hospital, Chongqing, China
| | - Junli Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyue Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofan Cao
- Department of Cardiology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yingxian Sun
- Department of Cardiology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Wenyu Hu
- Department of Cardiology, The First Affiliated Hospital, China Medical University, Shenyang, China.
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Abstract
We assessed the effect of body weight and BMI on plasma concentrations of venlafaxine (VEN), O-desmethylvenlafaxine (ODVEN), active moiety (AM=VEN+ODVEN), and dose-corrected plasma concentrations (C/D). A database containing concentrations of VEN and ODVEN including 737 of 1594 eligible patients was analyzed. Analyses included sex, body weight, and BMI as well as concentrations of VEN, ODVEN, AM, and C/D. A positive correlation was detected between body weight and daily dosage (rs=0.168, P<0.001). A negative correlation was found between body weight and AM (rs=-0.124, P=0.001) and ODVEN (rs=-0.137, P<0.001). Negative correlations were also found between body weight and C/D ratios (C/D VEN: rs=-0.134, P<0.001, C/D ODVEN: rs=-0.239, P<0.001, C/D AM: rs=-0.256, P<0.001). No correlations were detected between BMI and concentrations for VEN, ODVEN, and AM. Comparing low-BMI (<20 kg/m²), medium-BMI (20-29.9 kg/m²), and high-BMI (≥30 kg/m²) groups, higher values of some pharmacokinetic variables in the lower BMI group did not remain significant after controlling for sex. Women had higher VEN, ODVEN, AM, and C/D values for AM, VEN, and ODVEN than men (P<0.001 for all comparisons). Our results highlight the role of different pharmacokinetically relevant parameters and foremost of sex as mediators for the effect of BMI on VEN metabolism.
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15
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Pavlovic M, Apostolovic S, Stokanovic D, Lilic J, Konstantinovic SS, Zvezdanovic JB, Marinkovic V, Nikolic VN. The association of clopidogrel and 2-oxo-clopidogrel plasma levels and the 40 months clinical outcome after primary PCI. Int J Clin Pharm 2018; 40:1482-1489. [PMID: 30367373 DOI: 10.1007/s11096-018-0730-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 10/01/2018] [Indexed: 11/25/2022]
Abstract
Background A significant number of ischemic events occur even when adhering to dual antiplatelet therapy including aspirin and clopidogrel. Objectives The aim of our study was to determine predictors of long-term patient clinical outcome, among variables such as prodrug clopidogrel and intermediary metabolite 2-oxoclopidogrel concentrations, as well as patients' clinical characteristics. Setting Department for the Treatment of Acute Coronary Syndrome in tertiary teaching hospital, Serbia. Methods This study enrolled 88 consecutive patients with first STEMI, treated with primary PCI, within 6 h of the chest pain onset and followed them 40 months. On the third day of hospitalization, blood samples were collected from each patient to measure clopidogrel and its metabolite 2-oxo-clopidogrel concentration by UHPLC-DAD-MS method. Main outcome measure Mortality from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke or hospitalization for urgent myocardial revascularization or heart failure. Results The composite clinical outcome of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for urgent myocardial revascularization or heart failure, was registered in 31 patients (35.2%) during the 40-month follow-up. Lower clopidogrel (p < 0.05) and dose-adjusted clopidogrel concentrations (p < 0.05) were associated with the higher incidence of composite outcome events. Their low plasma concentrations may be predicted by fentanyl administration (p < 0.001) and creatinine clearance (p < 0.01). The decrease in dose-adjusted clopidogrel unit for each ng/ml/mg increases the risk 21.7 times (p < 0.05). Conclusion Clopidogrel dose-adjusted plasma concentration in STEMI patients, as well as multivessel coronary artery disease, showed significance in predicting an unfavorable composite clinical outcome after 40-month follow-up.
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Affiliation(s)
- Milan Pavlovic
- Department of Internal Medicine-Cardiology, Medical Faculty, University of Nis, Bulevar dr Zorana Djindjica 81, Nis, Serbia
- Clinic for Cardiovascular Diseases, Clinical Centre Nis, Bulevar dr Zorana Djindjica 48, Nis, Serbia
| | - Svetlana Apostolovic
- Department of Internal Medicine-Cardiology, Medical Faculty, University of Nis, Bulevar dr Zorana Djindjica 81, Nis, Serbia
- Clinic for Cardiovascular Diseases, Clinical Centre Nis, Bulevar dr Zorana Djindjica 48, Nis, Serbia
| | - Dragana Stokanovic
- Department of Pharmacology and Toxicology, Medical Faculty, University of Nis, Bulevar dr Zorana Djindjica 81, Nis, Serbia
| | - Jelena Lilic
- Medical Faculty, University of Nis, Bulevar dr Zorana Djindjica 81, Nis, Serbia
| | - Sandra S Konstantinovic
- Department of Chemistry, Faculty of Technology, University of Nis, Bulevar oslobodjenja 124, Leskovac, Serbia
| | - Jelena B Zvezdanovic
- Department of Chemistry, Faculty of Technology, University of Nis, Bulevar oslobodjenja 124, Leskovac, Serbia
| | - Valentina Marinkovic
- Department of Social Pharmacy and Pharmaceutical Legislation, Faculty of Pharmacy, University of Belegrade, Vojvode Stepe 450, Belgrade, Serbia
| | - Valentina N Nikolic
- Department of Pharmacology and Toxicology, Medical Faculty, University of Nis, Bulevar dr Zorana Djindjica 81, Nis, Serbia.
- Medicinski fakultet, Bulevar dr Zorana Djindjica 81, Nis, 18 000, Serbia.
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16
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Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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17
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Paulzen M, Haen E, Stegmann B, Hiemke C, Gründer G, Lammertz SE, Schoretsanitis G. Body mass index (BMI) but not body weight is associated with changes in the metabolism of risperidone; A pharmacokinetics-based hypothesis. Psychoneuroendocrinology 2016; 73:9-15. [PMID: 27448523 DOI: 10.1016/j.psyneuen.2016.07.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/02/2016] [Accepted: 07/08/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to unravel the influence of body weight and body mass index (BMI), both consistently reported as pharmacokinetic relevant parameters, on metabolism of risperidone in a naturalistic sample. METHODS Conducting non parametrical tests we sought for correlations between plasma concentrations of RIS, 9-OH-RIS and AM and body weight and BMI in patients out of a therapeutic drug monitoring (TDM) database. Further, we stratified patients to three groups based upon BMI values and compared drug concentrations between groups. RESULTS Although body weight failed to correlate with pharmacokinetic parameters, BMI was positively correlated with plasma concentrations of the active metabolite (9-OH-RIS) (rs=0.121, p=0.002) and active moiety (sum of RIS+9-OH-RIS) (rs=0.128, p=0.001) as well as dose adjusted plasma concentrations of the active moiety (rs=0.08, p=0.04). The comparison of pharmacokinetic parameters between different BMI groups yielded lower plasma concentrations of 9-OH-RIS in patients with low BMI (<20kg/m2) and higher plasma concentrations of the active moiety in obese patients (BMI ≥30kg/m2) when compared with the control group (30>BMI≥20kg/m2). By comparing low vs. high BMI patients, the latter group showed higher 9-OH-RIS plasma concentrations. CONCLUSIONS AND LIMITATIONS Considerable alterations in metabolism of risperidone were detected when comparing obese and cachectic patients with the control group in alignment with the positive correlation between BMI values and plasma concentrations of the active metabolite and active moiety as well as dose adjusted plasma concentrations of the active moiety. We suggest changes in CYP2D6 or CYP3A4 activity or differences in P-glycoprotein function in obese patients with greater BMI as a plausible mechanism underlying these alterations.
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Affiliation(s)
- Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Universitätsstrasse 84, 93053 Regensburg, Germany
| | - Benedikt Stegmann
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy and Department of Pharmacology and Toxicology, University of Regensburg, Universitätsstrasse 84, 93053 Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy and Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany
| | - Gerhard Gründer
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Sarah E Lammertz
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Georgios Schoretsanitis
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, and JARA - Translational Brain Medicine, Pauwelsstraße 30, 52074 Aachen, Germany; University Hospital of Psychiatry, Bolligenstrasse 111, 3000 Bern, Switzerland.
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18
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Westman PC, Lipinski MJ, Torguson R, Waksman R. A comparison of cangrelor, prasugrel, ticagrelor, and clopidogrel in patients undergoing percutaneous coronary intervention: A network meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 18:79-85. [PMID: 28089137 DOI: 10.1016/j.carrev.2016.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Newer P2Y12 inhibitors have more rapid onset of platelet inhibition compared with clopidogrel, especially the intravenous P2Y12 inhibitor cangrelor. Direct comparisons between cangrelor and oral P2Y12 inhibitors ticagrelor and prasugrel do not exist. Thus, we performed a network meta-analysis to directly and indirectly compare different P2Y12 inhibitors in patients undergoing percutaneous coronary intervention (PCI). METHODS MEDLINE/PubMed and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) that compared at least two P2Y12 inhibitors including cangrelor, clopidogrel, prasugrel, and ticagrelor. Network meta-analysis with a Bayesian approach was performed to directly and indirectly compare the effects of the aforementioned P2Y12 inhibitors on clinical outcomes. Odds ratios with credible intervals (OR [CrIs]) were generated with random-effects models to compare outcomes. RESULTS This analysis included 15 RCTs with 54,025 patients randomized to cangrelor (n=12,475), clopidogrel (n=26,903), prasugrel (n=7455), or ticagrelor (n=7192) at time of PCI. Patients had a mean age of 63±10, 74% were male, and 82% underwent PCI for acute coronary syndrome. No significant differences between cangrelor and clopidogrel were found with respect to cardiovascular death (OR 1.01 [CrI 0.23-4.39]), myocardial infarction (OR 0.94 [CrI 0.69-1.25]), major adverse cardiac events (OR 0.91 [CrI 0.69-1.18]), stent thrombosis (OR 0.66 [CrI 0.37-1.19]), or major bleeding (OR 1.52 [CrI 0.79-2.98]). Rank probability data suggested that ticagrelor and prasugrel were better than cangrelor for reducing ischemic events, though these differences were not significant. CONCLUSION Despite rapid platelet inhibition provided by cangrelor, newer oral P2Y12 inhibitors such as ticagrelor and prasugrel have comparable clinical outcomes.
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Affiliation(s)
- Peter C Westman
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Michael J Lipinski
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
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19
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Samant S, Jiang XL, Peletier LA, Shuldiner AR, Horenstein RB, Lewis JP, Lesko LJ, Schmidt S. Identifying clinically relevant sources of variability: The clopidogrel challenge. Clin Pharmacol Ther 2016; 101:264-273. [DOI: 10.1002/cpt.459] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/14/2022]
Affiliation(s)
- S Samant
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
| | - XL Jiang
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
| | - LA Peletier
- Mathematical Institute; Leiden University; PB 9512 2300 RA Leiden The Netherlands
| | - AR Shuldiner
- Division of Endocrinology, Diabetes and Nutrition; University of Maryland School of Medicine; Baltimore Maryland USA
| | - RB Horenstein
- Division of Endocrinology, Diabetes and Nutrition; University of Maryland School of Medicine; Baltimore Maryland USA
| | - JP Lewis
- Division of Endocrinology, Diabetes and Nutrition; University of Maryland School of Medicine; Baltimore Maryland USA
| | - LJ Lesko
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
| | - S Schmidt
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology; University of Florida at Lake Nona; Orlando Florida USA
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20
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Lee S, Hizoh I, Kovacs A, Horvath Z, Kiss N, Toth-Zsamboki E, Kiss RG. Predictors of high on-clopidogrel platelet reactivity in patients with acute coronary syndrome. Platelets 2015; 27:159-67. [PMID: 26247099 DOI: 10.3109/09537104.2015.1054799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
High on-clopidogrel platelet reactivity (HPR) is a predictor of ischemic events after percutaneous coronary intervention. We conducted a prospective cohort study to identify variables related to HPR in acute coronary syndrome patients who are at high thrombotic risk. We enrolled 463 patients undergoing urgent coronary angiography. Platelet reactivity was measured 12-36 hours after 600 mg clopidogrel loading with multiple electrode aggregometry (Multiplate® analyzer, Roche, Basel, Switzerland, 6.4 µM ADP). HPR was defined by the consensus cut-off area under the curve >46 U. The rate of HPR was 16.0%. We analyzed simple clinical and laboratory parameters with backward multivariate logistic regression and identified the following predictors of HPR: platelet count (per G/L, OR: 1.0073, 95% CI: 1.0035-1.0112, p = 0.0002), CRP level (per mg/L, OR: 1.0077, 95% CI: 1.0016-1.01372, p = 0.01), and active smoking (OR: 0.51, 95% CI: 0.29-0.89, p = 0.02). We developed and internally validated a risk prediction model demonstrating moderate discriminative capacity (area-under-the-receiver operating characteristic curve = 0.67). In conclusion, we found a relatively low rate of high on-clopidogrel platelet reactivity (16.0%) even in an acute patient cohort. HPR measured by Multiplate was associated with high platelet count and CRP level on admission and was inversely related to active smoking. The model with rapidly available simple parameters might help to identify individuals at risk for HPR in the acute setting.
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Affiliation(s)
- Sarolta Lee
- a School of Ph.D. Studies, Semmelweis University , Budapest , Hungary and
| | - Istvan Hizoh
- b Department of Cardiology , Medical Centre, Hungarian Defence Forces , Budapest , Hungary
| | - Andrea Kovacs
- b Department of Cardiology , Medical Centre, Hungarian Defence Forces , Budapest , Hungary
| | - Zsofia Horvath
- b Department of Cardiology , Medical Centre, Hungarian Defence Forces , Budapest , Hungary
| | - Nora Kiss
- b Department of Cardiology , Medical Centre, Hungarian Defence Forces , Budapest , Hungary
| | - Emese Toth-Zsamboki
- b Department of Cardiology , Medical Centre, Hungarian Defence Forces , Budapest , Hungary
| | - Robert Gabor Kiss
- b Department of Cardiology , Medical Centre, Hungarian Defence Forces , Budapest , Hungary
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Sabouret P, Rushton-Smith SK, Kerneis M, Silvain J, Collet JP, Montalescot G. Dual antiplatelet therapy: optimal timing, management, and duration. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:198-204. [PMID: 27533996 DOI: 10.1093/ehjcvp/pvv015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/18/2015] [Indexed: 12/27/2022]
Abstract
Platelet activation and aggregability play a key role in the genesis of arterial thrombus secondary to plaque rupture. For coronary patients, inhibition of platelet function is crucial to decrease the rate of major adverse cardiac events but may expose them to excess bleeding risk. Switching P2Y12 inhibitors is common, yet the clinical consequences are unknown. The aim of this review is to provide an overview of the evidence from randomized, clinical trials and epidemiological studies, with a focus on the optimal duration of dual antiplatelet therapy (DAPT) and appropriate agent and dose selection. The report discusses the latest evidence regarding switching therapies during DAPT, the potential benefits of a personalized strategy, management of the preoperative period, and other clinical perspectives in this complex and rapidly changing field. Ongoing trials will be useful to answer to some important unresolved questions.
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Affiliation(s)
- Pierre Sabouret
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | | | - Mathieu Kerneis
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | - Johanne Silvain
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | - Jean-Philippe Collet
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
| | - Gilles Montalescot
- Institut du Cœur, Pitié-Salpêtrière Hospital (AP-HP), Pierre and Marie Curie University, 47-83, boulevard de l'Hôpital, Paris 75013, France, ACTION Group, www.action-coeur.org
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