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Russo I, Brookles CG, Barale C, Melchionda E, Mousavi AH, Biolè C, Chinaglia A, Bianco M. Current Strategies to Guide the Antiplatelet Therapy in Acute Coronary Syndromes. Int J Mol Sci 2024; 25:3981. [PMID: 38612792 PMCID: PMC11011739 DOI: 10.3390/ijms25073981] [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: 02/18/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
The role of antiplatelet therapy in patients with acute coronary syndromes is a moving target with considerable novelty in the last few years. The pathophysiological basis of the treatment depends on platelet biology and physiology, and the interplay between these aspects and clinical practice must guide the physician in determining the best therapeutic options for patients with acute coronary syndromes. In the present narrative review, we discuss the latest novelties in the antiplatelet therapy of patients with acute coronary syndromes. We start with a description of platelet biology and the role of the main platelet signal pathways involved in platelet aggregation during an acute coronary syndrome. Then, we present the latest evidence on the evaluation of platelet function, focusing on the strengths and weaknesses of each platelet's function test. We continue our review by describing the role of aspirin and P2Y12 inhibitors in the treatment of acute coronary syndromes, critically appraising the available evidence from clinical trials, and providing current international guidelines and recommendations. Finally, we describe alternative therapeutic regimens to standard dual antiplatelet therapy, in particular for patients at high bleeding risk. The aim of our review is to give a comprehensive representation of current data on antiplatelet therapy in patients with acute coronary syndromes that could be useful both for clinicians and basic science researchers to be up-to-date on this complex topic.
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Affiliation(s)
- Isabella Russo
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Carola Griffith Brookles
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
- Department of Medical Sciences, University of Turin, I-10124 Turin, Italy
| | - Cristina Barale
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Elena Melchionda
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Amir Hassan Mousavi
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
- Department of Medical Sciences, University of Turin, I-10124 Turin, Italy
| | - Carloalberto Biolè
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
| | - Alessandra Chinaglia
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
| | - Matteo Bianco
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
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Capodanno D, Angiolillo DJ. Personalised antiplatelet therapies for coronary artery disease: what the future holds. Eur Heart J 2023; 44:3059-3072. [PMID: 37345589 DOI: 10.1093/eurheartj/ehad362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/07/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023] Open
Abstract
Coronary artery disease (CAD) is one of the leading causes of death globally, and antiplatelet therapy is crucial for both its prevention and treatment. Antiplatelet drugs such as aspirin and P2Y12 inhibitors are commonly used to reduce the risk of thrombotic events, including myocardial infarction, stroke, and stent thrombosis. However, the benefits associated with the use of antiplatelet drugs also come with a risk of bleeding complications. The ever-growing understanding of the poor prognostic implications associated with bleeding has set the foundations for defining strategies that can mitigate such safety concern without any trade-off in antithrombotic protection. To this extent, personalised antiplatelet therapy has emerged as a paradigm that optimizes the balance between safety and efficacy by customizing treatment to the individual patient's needs and risk profile. Accurate risk stratification for both bleeding and thrombosis can aid in selecting the optimal antiplatelet therapy and prevent serious and life-threatening outcomes. Risk stratification has traditionally included clinical and demographic characteristics and has expanded to incorporate angiographic features and laboratory findings. The availability of bedside platelet function testing as well as rapid genotyping assays has also allowed for a more individualized selection of antiplatelet therapy. This review provides a comprehensive overview of the current state of the art and future trends in personalised antiplatelet therapy for patients with CAD, with emphasis on those presenting with an acute coronary syndrome and undergoing percutaneous coronary revascularization. The aim is to provide clinicians with a comprehensive understanding of personalised antiplatelet therapy and facilitate informed clinical decision-making.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria 'G. Rodolico - San Marco', University of Catania, Via Santa Sofia, 78 - 95123 Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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Zhong PY, Deng JP, Zhao JH, Peng L, Liu T, Wang HY. Guided vs. conventional anti-platelet therapy for patients with acute coronary syndrome: A meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1079332. [PMID: 37025677 PMCID: PMC10070678 DOI: 10.3389/fcvm.2023.1079332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/24/2023] [Indexed: 04/08/2023] Open
Abstract
Background Whether guided antiplatelet therapy in patients with acute coronary syndrome (ACS) is effective in improving net clinical benefits compared with conventional antiplatelet therapy remains controversial. Therefore, we assessed the safety and efficacy of guided antiplatelet therapy in patients with ACS and undergoing percutaneous coronary intervention. Method We searched PubMed, EMBASE, and Cochrane Library databases to select the relevant randomized controlled trials comparing the guided and conventional antiplatelet therapy in patients with ACS. The primary and safety outcomes are major adverse cardiovascular events (MACE) and major bleeding, respectively. The efficacy outcomes included myocardial infarction, stent thrombosis, all-cause death, and cardiovascular death. We selected the relative risk (RR) and 95% confidence intervals (CIs) as effect size and calculated it using the Review Manager software. In addition, we evaluated the final results by trial sequential analysis (registered by PROSPERO, CRD 42020210912). Results We selected seven randomized controlled trials and included 8,451 patients in this meta-analysis. Guided antiplatelet therapy can significantly reduce the risk of MACE (RR 0.64, 95% CI 0.54-0.76, P < 0.00001), myocardial infarction (RR 0.62, 95% CI 0.49-0.79, P = 0.0001), all-cause death (RR 0.61, 95% CI 0.44-0.85, P = 0.003), and cardiovascular death (RR 0.66, 0.49-0.90, P = 0.009). In addition, there is no significant difference between the two groups in stent thrombosis (RR 0.67, 95% CI 0.44-1.03, P = 0.07) and major bleeding (RR 0.86, 95% CI 0.65-1.13, P = 0.27). The subgroup analysis showed that the guided group based on genotype tests could bring benefits in MACE and myocardial infarction. Conclusions The guided antiplatelet therapy is not only associated with a comparable risk of bleeding but also with a lower risk of MACE, myocardial infarction, all-cause death, cardiovascular death, and stent thrombosis than the conventional strategy in patients with ACS.
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Affiliation(s)
- Peng-Yu Zhong
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
| | - Jian-Ping Deng
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
| | - Jing-Hong Zhao
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
| | - Lei Peng
- Department of Urology, The Second Hospital of Lanzhou University Medical School, Lanzhou, China
- South China Hospital, Health Science Center, Shenzhen University, Shenzhen, China
| | - Tao Liu
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
- Correspondence: Tao Liu Hao-Yu Wang
| | - Hao-Yu Wang
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
- Correspondence: Tao Liu Hao-Yu Wang
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Galli M, Angiolillo DJ. De-escalation of antiplatelet therapy in acute coronary syndromes: Why, how and when? Front Cardiovasc Med 2022; 9:975969. [PMID: 36093167 PMCID: PMC9452742 DOI: 10.3389/fcvm.2022.975969] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 12/29/2022] Open
Abstract
The synergistic blockade of the key platelet signaling pathways of cyclooxygenase-1 blockade and P2Y12 signaling by combining aspirin plus a potent P2Y12 inhibitor (prasugrel or ticagrelor), the so called dual antiplatelet treatment (DAPT), has represented the antithrombotic regimen of choice in patients with acute coronary syndrome (ACS) for nearly a decade. Nevertheless, the use of such antiplatelet treatment regimen, while reduced the risk of thrombotic complications, it is inevitably associated with increased bleeding and this risk may outweigh the benefit of a reduction of ischemic events in specific subgroup of patients. In light of the adverse prognostic implications of a bleeding complication, there has been a great interest in the development of antiplatelet regimens aimed at reducing bleeding without any trade-off in ischemic events. The fact that the ischemic risk is highest in the early phase after an ACS while the risk of bleeding remains relatively stable over time has represented the rationale for the implementation of a more intense antithrombotic regimen early after an ACS, followed by a less intense antithrombotic regimen thereafter. This practice, known as a "de-escalation" strategy, represents one of the more promising approaches for personalization of antithrombotic therapy in ACS. In this review we discuss the rationale, appraise the evidence and provide practical recommendations on the use of a de-escalation strategy of antiplatelet therapy in patients with an ACS.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
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Galli M, Ortega-Paz L, Franchi F, Rollini F, Angiolillo DJ. Precision medicine in interventional cardiology: implications for antiplatelet therapy in patients undergoing percutaneous coronary intervention. Pharmacogenomics 2022; 23:723-737. [PMID: 35938534 DOI: 10.2217/pgs-2022-0057] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Precision medicine is a medical model that proposes the customization of medical treatments to the individual patient, as opposed to a one-drug-fits-all model. Such a "personalized medicine" approach has been widely adopted in several medical fields, such as cancer medicine, but the implementation of precision medicine in cardiovascular medicine has not been similarly straightforward. Because pharmacogenomics plays an important role in the safety and efficacy of cardiovascular drug therapy, there has been a great interest in the use of tools aiming at personalizing antiplatelet therapy. Moreover, antiplatelet therapy is essential for the treatment of cardiovascular patients to reduce the risk of thrombotic complications, particularly those undergoing percutaneous coronary intervention, but it is inevitably associated with increased bleeding risk. In this review, the authors discuss the rationale, summarize the evidence and discuss the current and future directions for the personalization of antiplatelet treatment regimens in patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 107] [Impact Index Per Article: 53.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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Galli M, Franchi F, Rollini F, Angiolillo DJ. Role of platelet function and genetic testing in patients undergoing percutaneous coronary intervention. Trends Cardiovasc Med 2021; 33:133-138. [PMID: 34936903 DOI: 10.1016/j.tcm.2021.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022]
Abstract
Dual antiplatelet therapy (DAPT) represents the standard of care for patients undergoing percutaneous coronary intervention (PCI). Increasing evidence indicates that a "one-size-fits-all" approach with the use of a standard DAPT regimen for all patients undergoing PCI could lead to either suboptimal efficacy or prohibitively high bleeding in specific cohorts of patients. Moreover, the broad interindividual variability in response to P2Y12 inhibitors can impact outcomes and resource utilization. Among the strategies proposed to provide a more balanced trade-off between bleeding and ischemic events at a single patient level, a guided selection of P2Y12 inhibitors, by using platelet function or genetic testing, has shown promising results. In this review, we provide a focused summary of the rationale and evidence on the use of platelet function and genetic testing-guided antiplatelet therapy, and we explore the implications for their use in the modern setting of patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States.
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Martin AK, Feinman JW, Bhatt HV, Subramani S, Malhotra AK, Townsley MM, Fritz AV, Sharma A, Patel SJ, Zhou EY, Owen RM, Ghofaily LA, Read SN, Teixeira MT, Arora L, Jayaraman AL, Weiner MM, Ramakrishna H. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2021. J Cardiothorac Vasc Anesth 2021; 36:940-951. [PMID: 34801393 DOI: 10.1053/j.jvca.2021.10.011] [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] [Received: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 11/11/2022]
Abstract
This special article is the fourteenth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2021 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2021 begin with an update on structural heart disease, with a focus on updates in arrhythmia and aortic valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and procedural management. The third major theme is focused on the perioperative management of patients with COVID-19, with the authors highlighting literature discussing the impact of the disease on the right ventricle and thromboembolic events. The fourth and final theme is an update in heart failure, with discussion of diverse aspects of this area. The themes selected for this fourteenth special article are only a few of the diverse advances in the specialty during 2021. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.
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Affiliation(s)
- Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Himani V Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita K Malhotra
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Saumil J Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Y Zhou
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert M Owen
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lourdes Al Ghofaily
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Selina N Read
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Miguel T Teixeira
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Lovkesh Arora
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Arun L Jayaraman
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, AZ
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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Galli M, Franchi F, Rollini F, Cavallari LH, Capodanno D, Crea F, Angiolillo DJ. Genetic testing in patients undergoing percutaneous coronary intervention: rationale, evidence and practical recommendations. Expert Rev Clin Pharmacol 2021; 14:963-978. [PMID: 33993817 PMCID: PMC9008593 DOI: 10.1080/17512433.2021.1927709] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/06/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Clopidogrel is the most frequently utilized P2Y12 inhibitor and is characterized by broad interindividual response variability resulting in impaired platelet inhibition and increased risk of thrombotic complications in a considerable number of patients. The potent P2Y12 inhibitors, prasugrel and ticagrelor, can overcome this limitation but at the expense of an increased risk of bleeding. Genetic variations of the cytochrome P450 (CYP) 2 C19 enzyme, a key determinant in clopidogrel metabolism, have been strongly associated with clopidogrel response profiles prompting investigations of genetic-guided selection of antiplatelet therapy. AREAS COVERED The present manuscript focuses on the rationale for the use of genetic testing to guide the selection of platelet P2Y12 inhibitors among patients undergoing percutaneous coronary intervention (PCI). Moreover, a comprehensive appraisal of the available evidence and practical recommendations is provided. EXPERT COMMENTARY Implementation of genetic testing as a strategy to guide the selection of therapy can result in escalation (i.e. switching to prasugrel or ticagrelor) or de-escalation (i.e. switching to clopidogrel) of P2Y12 inhibiting therapy. Most recent investigations support the clinical benefit of a genetic guided selection of antiplatelet therapy in patients undergo PCI. Integrating the results of genetic testing with clinical and procedural variables represents a promising strategy for a precision medicine approach for the selection of antiplatelet therapy among patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Galli M, Angiolillo DJ. Antiplatelet therapy in percutaneous coronary intervention: latest evidence from randomized controlled trials. Curr Opin Cardiol 2021; 36:390-396. [PMID: 33973929 DOI: 10.1097/hco.0000000000000879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antiplatelet therapy is key to reduce systemic and local thrombotic events among patients undergoing percutaneous coronary interventions (PCI). Antiplatelet treatment regimens have been subject to continuous changes over the years, with a dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor representing the cornerstone of treatment in these patients. RECENT FINDINGS The need for less aggressive antithrombotic drugs to prevent local ischemic events with newer generation drug-eluting stent together with the increased understanding of the prognostic relevance of bleeding events in PCI patients, have prompted investigations aimed at identifying antiplatelet treatment regimens associated with a more favorable balance between ischemic and bleeding risks. Several key randomized controlled trials (RCTs) on antiplatelet regimens in patients undergoing PCI have been recently reported resulting in updates in practice guidelines. SUMMARY This manuscript provides an overview of the advancements in the field deriving from key RCTs on antiplatelet regimens in patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Cao D, Chandiramani R, Chiarito M, Claessen BE, Mehran R. Evolution of antithrombotic therapy in patients undergoing percutaneous coronary intervention: a 40-year journey. Eur Heart J 2021; 42:339-351. [PMID: 33367641 DOI: 10.1093/eurheartj/ehaa824] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/02/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
Since its introduction in 1977, percutaneous coronary intervention has become one of the most commonly performed therapeutic procedures worldwide. Such widespread diffusion, however, would have not been possible without a concomitant evolution of the pharmacotherapies associated with this intervention. Antithrombotic agents are fundamental throughout the management of patients undergoing coronary stent implantation, starting from the procedure itself to the long-term prevention of cardiovascular events. The last 40 years of interventional cardiology have seen remarkable improvements in both drug therapies and device technologies, which largely reflected a progressive understanding of the pathophysiological mechanisms of coronary artery disease, as well as procedure- and device-related adverse events. The purpose of this article is to provide an overview of the important milestones in antithrombotic pharmacology that have shaped clinical practice of today while also providing insights into knowledge gaps and future directions.
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Affiliation(s)
- Davide Cao
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Rishi Chandiramani
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Mauro Chiarito
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy.,Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Via Alessandro Manzoni 56, 20090 Rozzano, Milan, Italy
| | - Bimmer E Claessen
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Roxana Mehran
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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Galli M, Benenati S, Capodanno D, Franchi F, Rollini F, D'Amario D, Porto I, Angiolillo DJ. Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Lancet 2021; 397:1470-1483. [PMID: 33865495 DOI: 10.1016/s0140-6736(21)00533-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/18/2021] [Accepted: 02/23/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Whether guided selection of antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) is effective in improving outcomes compared with standard antiplatelet therapy remains controversial. We assessed the safety and efficacy of guided versus standard selection of antiplatelet therapy in patients undergoing PCI. METHODS For this systematic review and meta-analysis, from Aug 20 to Oct 25, 2020, we searched MEDLINE (via PubMed), Cochrane, Embase, and Web of Science databases for randomised controlled trials and observational studies published in any language that compared guided antiplatelet therapy, by means of platelet function testing or genetic testing, versus standard antiplatelet therapy in patients undergoing PCI. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% CIs were used with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Coprimary endpoints were trial-defined primary major adverse cardiovascular events and any bleeding. Key secondary endpoints were all-cause death, cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and major and minor bleeding. This study is registered with PROSPERO (CRD42021215901). FINDINGS 3656 potentially relevant articles were screened. Our analysis included 11 randomised controlled trials and three observational studies with data for 20 743 patients. Compared with standard therapy, guided selection of antiplatelet therapy was associated with a reduction in major adverse cardiovascular events (RR 0·78, 95% CI 0·63-0·95, p=0·015) and reduced bleeding, although not statistically significant (RR 0·88, 0·77-1·01, p=0·069). Cardiovascular death (RR 0·77, 95% CI 0·59-1·00, p=0·049), myocardial infarction (RR 0·76, 0·60-0·96, p=0·021), stent thrombosis (RR 0·64, 0·46-0·89, p=0·011), stroke (RR 0·66, 0·48-0·91, p=0·010), and minor bleeding (RR 0·78, 0·67-0·92, p=0·0030) were reduced with guided therapy compared with standard therapy. Risks of all-cause death and major bleeding did not differ between guided and standard approaches. Outcomes varied according to the strategy used, with an escalation approach associated with a significant reduction in ischaemic events without any trade-off in safety, and a de-escalation approach associated with a significant reduction in bleeding, without any trade-off in efficacy. INTERPRETATION Guided selection of antiplatelet therapy improved both composite and individual efficacy outcomes with a favourable safety profile, driven by a reduction in minor bleeding, supporting the use of platelet function or genetic testing to optimise the choice of agent in patients undergoing PCI. FUNDING None.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy; Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stefano Benenati
- Department of Internal Medicine and Medical Specialties (DIMI) Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico Gaspare Rodolico-San Marco, University of Catania, Catania, Italy
| | - Francesco Franchi
- 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
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI) Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy; DICATOV Cardiothoracic and Vascular Department, San Martino Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Dominick J Angiolillo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
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Franchi F, Rollini F. Genotype-Guided Antiplatelet Therapy in Patients With Coronary Artery Disease. JACC Cardiovasc Interv 2021; 14:751-753. [PMID: 33744206 DOI: 10.1016/j.jcin.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Francesco Franchi
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA.
| | - Fabiana Rollini
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
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14
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Gao R, Xu B. CCI and CIT 2020-A special year of the special issue. Catheter Cardiovasc Interv 2021; 95 Suppl 1:532-533. [PMID: 32144899 DOI: 10.1002/ccd.28808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Runlin Gao
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Bo Xu
- Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Galli M, Capodanno D, Andreotti F, Crea F, Angiolillo DJ. Safety and efficacy of P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary interventions. Expert Opin Drug Saf 2020; 20:9-21. [PMID: 33180563 DOI: 10.1080/14740338.2021.1850691] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI. Areas covered: P2Y12 inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y12 inhibitor monotherapy in patients undergoing PCI in different clinical settings. Expert opinion: P2Y12 inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y12 monotherapy regimen warrant further investigation.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy.,Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico," Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
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16
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Zhao X, Li Q, Tu C, Zeng Y, Ye Y. High glycated albumin is an independent predictor of low response to clopidogrel in ACS patients: a cross-sectional study. Cardiovasc Diabetol 2020; 19:171. [PMID: 33036613 PMCID: PMC7545941 DOI: 10.1186/s12933-020-01146-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/29/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Glycated albumin (GA) is a marker of short-term glycemic control and is strongly associated with the occurrence of diabetes. Previous studies have shown an association between GA and the effect of clopidogrel therapy on ischemic stroke. However, limited information is available regarding this relationship in acute coronary syndrome (ACS) patients. In this study, we evaluated the effect of GA on platelet P2Y12 inhibition by clopidogrel in patients with ACS. METHODS Consecutive Chinese patients with ACS who received loading or maintenance doses of clopidogrel in addition to aspirin were recruited. At least 12 h after the patient had taken the clopidogrel dose, thromboelastography (TEG) and light transmittance aggregometry (LTA) were used to calculate the quantitative platelet inhibition rate to determine clopidogrel-induced antiplatelet reactivity. A prespecified cutoff of the maximum amplitude of adenosine diphosphate (ADP)-induced platelet-fibrin clot strength > 47 mm plus an ADP-induced platelet inhibition rate < 50% assessed by TEG or ADP-induced platelet aggregation > 40% assessed by LTA to indicate low responsiveness to clopidogrel were applied for evaluation. Patients were categorized into two groups based on a GA level of 15.5%, the cutoff point indicating the development of early-phase diabetes. Multivariate linear regression analysis was used to assess the interaction of GA with clopidogrel antiplatelet therapy. RESULTS A total of 1021 participants were evaluated, and 28.3% of patients (289 of 1021) had low responsiveness to clopidogrel assessed by TEG. In patients with elevated GA levels, low responsiveness to clopidogrel assessed by TEG was observed in 33.7% (139 of 412) of patients, which was a significantly higher rate than that in the lower-GA-level group (24.6%, P = 0.002). According to multivariate linear regression analysis, a GA level > 15.5% was independently associated with low responsiveness to clopidogrel after adjustment for age, sex and other conventional confounding factors. This interaction was not mediated by a history of diabetes mellitus. A GA level ≤ 15.5% was associated with a high positive value [75.4%, 95% CI 73.0-77.6%] for predicting a normal responsiveness to clopidogrel. CONCLUSIONS GA could be a potential biomarker to predict the effects of clopidogrel antiplatelet therapy in ACS patients and might be a clinical biomarker to guide DAPT de-escalation.
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Affiliation(s)
- Xiliang Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Quan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Chenchen Tu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Yong Zeng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Yicong Ye
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
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Abstract
Studies using whole blood platelet aggregometry as a laboratory research tool, provided important insights into the mechanism and modulators of platelet aggregation. Subsequently, a number of point-of-care (POC) platelet function tests (PFTs) were developed for clinical use, based on the concept that an individual’s thrombotic profile could be assessed in vitro by assessing the response to stimulation of platelet aggregation by specific, usually solo agonists such as adenosine diphosphate (ADP), collagen and thrombin. However, adjusting antiplatelet medication in order to improve the results of such POC PFTs has not translated into a meaningful reduction in cardiovascular events, which may be attributable to important differences between the POC PFT techniques and in vivo conditions, including patient-to-patient variability. Important limitations of most tests include the use of citrate-anticoagulated blood. Citrate directly and irreversibly diminishes platelet function and even after recalcification, it may result in altered platelet aggregation in response to ADP, epinephrine or collagen, and interfere with thrombin generation from activated platelets. Furthermore, most tests do not employ flowing blood and therefore do not assess the effect of high shear forces on platelets that initiate, propagate and stabilize arterial thrombi. Finally, the effect of endogenous thrombolysis, due to fibrinolysis and dislodgement, which ultimately determines the outcome of a thrombotic stimulus, is mostly not assessed. In order to accurately reflect an individual’s predisposition to arterial thrombosis, future tests of thrombotic status which overcome these limitations should be used, to improve cardiovascular risk prediction and to guide pharmacotherapy.
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Affiliation(s)
- Diana A Gorog
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
- University of Hertfordshire, Hertfordshire, UK.
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18
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Masiero G, Rossini R. De-escalation therapy after acute coronary syndrome: is it reasonable to switch from prasugrel (or ticagrelor) to clopidogrel early? Eur Heart J Suppl 2020; 22:E132-E136. [PMID: 32523457 PMCID: PMC7270966 DOI: 10.1093/eurheartj/suaa078] [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] [Indexed: 11/13/2022]
Abstract
Dual antiplatelet treatment (DAPT) is the treatment of choice to prevent atherothrombotic events in patients with acute coronary syndrome (ACS) treated with percutaneous interventions (PCIs). The availability of different P2Y12 inhibitors set the stage for costum made DAPT, as to achieve the highest profile of safety and efficacy. The de-escalation therapy for the newer and more powerful antiplatelet drugs, such as ticagrelor and prasugrel, to clopidogrel, is a strategy for patients with recent ACS, unfit for continuing DAPT for their high risk of bleeding, or side effects, or socio-economic reasons, but without a prohibitive ischaemic risk. There is a need for compelling clinical evidences able to provide the clinical cardiologist with the necessary information to decide the best antiplatelet strategy for each individual patient.
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Affiliation(s)
- Giulia Masiero
- USC Cardiologia, Ospedale Santa Croce e Carle, via M. Coppino, 26, Cuneo, Italy
| | - Roberta Rossini
- USC Cardiologia, Ospedale Santa Croce e Carle, via M. Coppino, 26, Cuneo, Italy
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19
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Franchi F, Rollini F, Rivas J, Rivas A, Agarwal M, Briceno M, Wali M, Nawaz A, Silva G, Shaikh Z, Maailiki N, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Prasugrel Versus Ticagrelor in Patients With CYP2C19 Loss-of-Function Genotypes: Results of a Randomized Pharmacodynamic Study in a Feasibility Investigation of Rapid Genetic Testing. JACC Basic Transl Sci 2020; 5:419-428. [PMID: 32478205 PMCID: PMC7251226 DOI: 10.1016/j.jacbts.2020.02.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/08/2020] [Indexed: 12/22/2022]
Abstract
The feasibility of rapid genetic testing in patients undergoing percutaneous coronary intervention (PCI) and the comparison of the pharmacodynamic effects of prasugrel versus ticagrelor among carriers of cytochrome P450 2C19 loss-of-function alleles treated with PCI has been poorly explored. Rapid genetic testing using the Spartan assay was shown to be feasible and provides results in a timely fashion in a real-world setting of patients undergoing coronary angiography (n = 781). Among patients (n = 223, 28.5%), carriers of at least 1 loss-of-function allele treated with PCI (n = 65), prasugrel, and ticagrelor achieve similar levels of platelet inhibition. (A Pharmacodynamic Study Comparing Prasugrel Versus Ticagrelor in Patients Undergoing PCI With CYP2C19 Loss-of-function [NCT02065479]).
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Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Jose Rivas
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andrea Rivas
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Malhar Agarwal
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Maryuri Briceno
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Mustafa Wali
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Ahmed Nawaz
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Gabriel Silva
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Zubair Shaikh
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Naji Maailiki
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Latonya Been
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andres M. Pineda
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Siva Suryadevara
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Daniel Soffer
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Martin M. Zenni
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Theodore A. Bass
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
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20
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Angiolillo DJ, Capodanno D, Danchin N, Simon T, Bergmeijer TO, ten Berg JM, Sibbing D, Price MJ. Derivation, Validation, and Prognostic Utility of a Prediction Rule for Nonresponse to Clopidogrel. JACC Cardiovasc Interv 2020; 13:606-617. [DOI: 10.1016/j.jcin.2020.01.226] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022]
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You J, Li H, Guo W, Li J, Gao L, Wang Y, Geng L, Wang X, Wan Q, Zhang Q. Platelet function testing guided antiplatelet therapy reduces cardiovascular events in Chinese patients with ST‐segment elevation myocardial infarction undergoing percutaneous coronary intervention: The PATROL study. Catheter Cardiovasc Interv 2020; 95 Suppl 1:598-605. [DOI: 10.1002/ccd.28712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/28/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Jieyun You
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Hongda Li
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Wei Guo
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Jiming Li
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Liming Gao
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Yunkai Wang
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Liang Geng
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Xingxu Wang
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Qing Wan
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Qi Zhang
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
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Sibbing D, Angiolillo DJ. Reply: Therapeutic Window of P2Y 12 Inhibition: Should the Current Limits Be Modified? JACC Cardiovasc Interv 2019; 12:2434-2435. [PMID: 31806222 DOI: 10.1016/j.jcin.2019.10.015] [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: 10/01/2019] [Accepted: 10/08/2019] [Indexed: 11/18/2022]
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Buccheri S, Capodanno D, James S, Angiolillo DJ. Bleeding after antiplatelet therapy for the treatment of acute coronary syndromes: a review of the evidence and evolving paradigms. Expert Opin Drug Saf 2019; 18:1171-1189. [DOI: 10.1080/14740338.2019.1680637] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Sergio Buccheri
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. “G. Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Capodanno D, Angiolillo DJ. Tailoring Antiplatelet Therapy in Patients Undergoing Transcatheter Aortic Valve Replacement: Navigating the Unknown. JACC Cardiovasc Interv 2019; 12:33-37. [PMID: 30621975 DOI: 10.1016/j.jcin.2018.10.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/23/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy.
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[Platelet GPⅠb-Ⅸ-Ⅴ receptor-mediated mechanism and its application in thrombotic diseases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:532-536. [PMID: 31340631 PMCID: PMC7342399 DOI: 10.3760/cma.j.issn.0253-2727.2019.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sibbing D, Aradi D, Alexopoulos D, ten Berg J, Bhatt DL, Bonello L, Collet JP, Cuisset T, Franchi F, Gross L, Gurbel P, Jeong YH, Mehran R, Moliterno DJ, Neumann FJ, Pereira NL, Price MJ, Sabatine MS, So DY, Stone GW, Storey RF, Tantry U, Trenk D, Valgimigli M, Waksman R, Angiolillo DJ. Updated Expert Consensus Statement on Platelet Function and Genetic Testing for Guiding P2Y12 Receptor Inhibitor Treatment in Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 12:1521-1537. [DOI: 10.1016/j.jcin.2019.03.034] [Citation(s) in RCA: 250] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 12/22/2022]
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Angiolillo DJ, Patti G, Chan KT, Han Y, Huang WC, Yakovlev A, Paek D, Del Aguila M, Girotra S, Sibbing D. De-escalation from ticagrelor to clopidogrel in acute coronary syndrome patients: a systematic review and meta-analysis. J Thromb Thrombolysis 2019; 48:1-10. [PMID: 31004312 PMCID: PMC6556170 DOI: 10.1007/s11239-019-01860-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2-28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1-4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4-4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation.
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Affiliation(s)
- Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, ACC Building 5th floor, 655 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Giuseppe Patti
- Chair of Cardiology, University of L'Aquila, Via Camponeschi, 19, L'Aquila, Italy
| | - Kam Tim Chan
- Director of Cardiac Catheterization and Interventional Laboratory, Consultant Cardiologist, Queen Elizabeth Hospital, 30 Gascoigne Rd, King's Park, Hong Kong, Hong Kong
| | - Yaling Han
- Department of Cardiology, The General Hospital of Shenyang Military Region, 83 Wenhua Rd, Shenhe District, Shenyang City, Liaoning, China
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386 Dazhong 1st Road, Zuoying District, Kaohsiung City, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Alexey Yakovlev
- Almazov National Medical Research Centre, 12 Mayakovsky St, Saint Petersburg, Russia
| | - Dara Paek
- Doctor Evidence, 301 Arizona Ave #301, Santa Monica, CA, USA
| | | | - Shalini Girotra
- Sanofi, General Medicine and Emerging Markets, 38 Beach Road, Singapore, Singapore
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Marchioninistraße 15, 81377, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Angiolillo DJ. Editorial commentary: Evolving paradigms in antithrombotic therapy for patients with coronary artery disease undergoing percutaneous coronary intervention. Trends Cardiovasc Med 2019; 30:203-204. [PMID: 31230913 DOI: 10.1016/j.tcm.2019.06.004] [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: 06/07/2019] [Accepted: 06/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville 32209, FL, USA.
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Greco A, Capranzano P, Barbanti M, Tamburino C, Capodanno D. Antithrombotic pharmacotherapy after transcatheter aortic valve implantation: an update. Expert Rev Cardiovasc Ther 2019; 17:479-496. [PMID: 31198065 DOI: 10.1080/14779072.2019.1632189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for a large proportion of patients with severe aortic stenosis. Despite numerous technological and clinical advances, TAVI remains associated with thrombotic complications requiring antithrombotic pharmacotherapy, which exposes to the risk of bleeding, especially in elderly individuals. The optimal antithrombotic regimen following TAVI is uncertain and several investigations are ongoing. Areas covered: Clinical guidelines are mostly driven by observational trials and experts' opinions, thus resulting into low-grade level of evidence. The aim of the current review is to critically explore the epidemiology, pathophysiology and prognostic value of thrombotic and bleeding events after TAVI, and to review the current literature on antithrombotic strategies following the procedure. Expert opinion: Thrombotic and bleeding events remain major complications occurring in the frail population that is currently offered TAVI. Waiting for upcoming evidence from ongoing randomized clinical trials, tailoring antithrombotic therapies based on patients' characteristics, values and circumstances is a preferable approach.
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Affiliation(s)
- Antonio Greco
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Piera Capranzano
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Marco Barbanti
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Corrado Tamburino
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Davide Capodanno
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
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Senzel L, Ahmed T, Spitzer ED. Laboratory Monitoring of Platelet P2Y12 Receptor Inhibitors and Reversal of Antiplatelet Agents. Am J Clin Pathol 2019; 152:1-6. [PMID: 30395148 DOI: 10.1093/ajcp/aqy151] [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: 01/27/2023] Open
Abstract
OBJECTIVES To review the use of laboratory tests for antiplatelet agents to determine escalation of antiplatelet therapy and for emergent reversal of P2Y12 inhibitors. METHODS A case scenario and review of cardiovascular and neurointerventional literature are described. RESULTS In cardiovascular disease patients, large randomized trials failed to demonstrate superiority of tailored antiplatelet regimens using the VerifyNow P2Y12 assay, where earlier studies had shown promise. Platelet transfusions restored platelet function measured by vasodilator-stimulated phosphoprotein, light transmission aggregometry, or thromboelastography but not VerifyNow P2Y12, with the most restoration for clopidogrel and the least for ticagrelor. CONCLUSIONS Current evidence does not support changing antiplatelet therapy based on the results of platelet function monitoring tests. For emergent reversal of P2Y12 inhibitors, test method can affect platelet dosing recommendations, as different methods may give different results.
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Affiliation(s)
- Lisa Senzel
- Stony Brook University Medical Center, Stony Brook, NY
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31
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Esmail K, Angiolillo DJ. Antiplatelet Therapy Considerations in Women. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kheiri B, Osman M, Abdalla A, Haykal T, Pandrangi PV, Chahine A, Ahmed S, Osman K, Bachuwa G, Hassan M, Bhatt DL. CYP2C19
pharmacogenetics versus standard of care dosing for selecting antiplatelet therapy in patients with coronary artery disease: A meta-analysis of randomized clinical trials. Catheter Cardiovasc Interv 2018; 93:1246-1252. [DOI: 10.1002/ccd.27949] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 09/05/2018] [Accepted: 10/08/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Mohammed Osman
- Division of Cardiology; West Virginia University School of Medicine; Morgantown West Virginia
| | - Ahmed Abdalla
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Tarek Haykal
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Pranay V. Pandrangi
- Department of Internal Medicine; Spectrum Health/Michigan State University; Grand Rapids Michigan
| | - Adam Chahine
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Sahar Ahmed
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Khansa Osman
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Ghassan Bachuwa
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Mustafa Hassan
- Department of Internal Medicine; Hurley Medical Center/Michigan State University; Flint Michigan
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School; Boston Massachusetts
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Franchi F, Rollini F, Rivas Rios J, Rivas A, Agarwal M, Kureti M, Nagaraju D, Wali M, Shaikh Z, Briceno M, Nawaz A, Moon JY, Been L, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Pharmacodynamic Effects of Switching From Ticagrelor to Clopidogrel in Patients With Coronary Artery Disease. Circulation 2018. [DOI: 10.1161/circulationaha.118.033983] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
| | | | | | - Andrea Rivas
- University of Florida College of Medicine–Jacksonville
| | | | - Megha Kureti
- University of Florida College of Medicine–Jacksonville
| | | | - Mustafa Wali
- University of Florida College of Medicine–Jacksonville
| | - Zubair Shaikh
- University of Florida College of Medicine–Jacksonville
| | | | - Ahmed Nawaz
- University of Florida College of Medicine–Jacksonville
| | - Jae Youn Moon
- University of Florida College of Medicine–Jacksonville
| | - Latonya Been
- University of Florida College of Medicine–Jacksonville
| | | | - Daniel Soffer
- University of Florida College of Medicine–Jacksonville
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Cavallari LH, Franchi F, Rollini F, Been L, Rivas A, Agarwal M, Smith DM, Newsom K, Gong Y, Elsey AR, Starostik P, Johnson JA, Angiolillo DJ. Clinical implementation of rapid CYP2C19 genotyping to guide antiplatelet therapy after percutaneous coronary intervention. J Transl Med 2018; 16:92. [PMID: 29642909 PMCID: PMC5896099 DOI: 10.1186/s12967-018-1469-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/31/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The CYP2C19 nonfunctional genotype reduces clopidogrel effectiveness after percutaneous coronary intervention (PCI). Following clinical implementation of CYP2C19 genotyping at University Florida (UF) Health Shands Hospital in 2012, where genotype results are available approximately 3 days after PCI, testing was expanded to UF Health Jacksonville in 2016 utilizing a rapid genotyping approach. We describe metrics with this latter implementation. METHODS Patients at UF Health Jacksonville undergoing left heart catheterization with intent to undergo PCI were targeted for genotyping using the Spartan RX™ system. Testing metrics and provider acceptance of testing and response to genotype results were examined, as was antiplatelet therapy over the 6 months following genotyping. RESULTS In the first year, 931 patients, including 392/505 (78%) total patients undergoing PCI, were genotyped. The median genotype test turnaround time was 96 min. Genotype results were available for 388 (99%) PCI patients prior to discharge. Of 336 genotyped PCI patients alive at discharge and not enrolled in an antiplatelet therapy trial, 1/6 (17%) poor metabolizers (PMs, with two nonfunctional alleles), 38/93 (41%) intermediate metabolizers (IMs, with one nonfunctional allele), and 119/237 (50%) patients without a nonfunctional allele were prescribed clopidogrel (p = 0.110). Clopidogrel use was higher among non-ACS versus ACS patients (78.6% vs. 42.2%, p < 0.001). Six months later, among patients with follow-up data, clopidogrel was prescribed in 0/4 (0%) PMs, 33/65 (51%) IMs, and 115/182 (63%) patients without a nonfunctional allele (p = 0.008 across groups; p = 0.020 for PMs versus those without a nonfunctional allele). CONCLUSION These data demonstrate that rapid genotyping is clinically feasible at a high volume cardiac catheterization facility and allows informed chronic antiplatelet prescribing, with lower clopidogrel use in PMs at 6 months. Trial registration ClinicalTrials.gov Identifier: NCT02724319; registered March 31, 2016; https://www.clinicaltrials.gov/ct2/show/NCT02724319?term=angiolillo&rank=7.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL USA
| | - Francesco Franchi
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Fabiana Rollini
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Latonya Been
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Andrea Rivas
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - Malhar Agarwal
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
| | - D. Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
| | - Kimberly Newsom
- University of Florida Health Pathology Laboratories, Gainesville, FL USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
| | - Amanda R. Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL USA
| | - Petr Starostik
- University of Florida Health Pathology Laboratories, Gainesville, FL USA
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL USA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL USA
- Center for Pharmacogenomics, University of Florida, Gainesville, FL USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL USA
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida, Jacksonville, FL USA
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Notarangelo FM, Maglietta G, Bevilacqua P, Cereda M, Merlini PA, Villani GQ, Moruzzi P, Patrizi G, Malagoli Tagliazucchi G, Crocamo A, Guidorossi A, Pigazzani F, Nicosia E, Paoli G, Bianchessi M, Comelli MA, Caminiti C, Ardissino D. Pharmacogenomic Approach to Selecting Antiplatelet Therapy in Patients With Acute Coronary Syndromes: The PHARMCLO Trial. J Am Coll Cardiol 2018. [PMID: 29540324 DOI: 10.1016/j.jacc.2018.02.029] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although clopidogrel is still frequently used in patients with acute coronary syndromes (ACS), its efficacy is hampered by interpatient response variability caused by genetic polymorphisms associated with clopidogrel's metabolism. OBJECTIVES The goal of this study was to evaluate whether selecting antiplatelet therapy (clopidogrel, prasugrel, or ticagrelor) on the basis of a patient's genetic and clinical characteristics leads to better clinical outcomes compared with the standard of care, which bases the selection on clinical characteristics alone. METHODS Patients hospitalized for ACS were randomly assigned to standard of care or the pharmacogenomic arm, which included the genotyping of ABCB1, CYP2C19*2, and CYP2C19*17 using an ST Q3 system that provides data within 70 min at each patient's bedside. The patients were followed up for 12 ± 1 month for the primary composite endpoint of cardiovascular death and the first occurrence of nonfatal myocardial infarction, nonfatal stroke, and major bleeding defined according to Bleeding Academic Research Consortium type 3 to 5 criteria. RESULTS After enrolling 888 patients, the study was prematurely stopped. Clopidogrel was used more frequently in the standard-of-care arm (50.7% vs. 43.3%), ticagrelor in the pharmacogenomic arm (42.6% vs. 32.7%; p = 0.02), and prasugrel was equally used in both arms. The primary endpoint occurred in 71 patients (15.9%) in the pharmacogenomic arm and in 114 (25.9%) in the standard-of-care arm (hazard ratio: 0.58; 95% confidence interval: 0.43 to 0.78; p < 0.001). CONCLUSIONS A personalized approach to selecting antiplatelet therapy for patients with ACS may reduce ischemic and bleeding events. (Pharmacogenetics of Clopidogrel in Patients With Acute Coronary Syndromes [PHARMCLO]; NCT03347435).
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Affiliation(s)
| | - Giuseppe Maglietta
- Division of Research and Innovation, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy; Department of Statistics, Computer Science, Applications, Università di Firenze, Florence, Italy
| | - Paola Bevilacqua
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Marco Cereda
- ST Microelectronics S.R.L., Agrate Brianza, Monza Brianza, Italy
| | | | | | - Paolo Moruzzi
- Division of Cardiology, Azienda Territoriale di Parma, Fidenza, Italy
| | - Giampiero Patrizi
- Division of Cardiology, Azienda Territoriale di Modena, Carpi, Italy
| | - Guidantonio Malagoli Tagliazucchi
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy; Division of Research and Innovation, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonio Crocamo
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angela Guidorossi
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Filippo Pigazzani
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Elisa Nicosia
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Giorgia Paoli
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Marco Bianchessi
- ST Microelectronics S.R.L., Agrate Brianza, Monza Brianza, Italy
| | | | - Caterina Caminiti
- Division of Research and Innovation, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Diego Ardissino
- Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
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36
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Moon JY, Franchi F, Rollini F, Angiolillo DJ. The quest for safer antithrombotic treatment regimens in patients with coronary artery disease: new strategies and paradigm shifts. Expert Rev Hematol 2017; 11:5-12. [DOI: 10.1080/17474086.2018.1400378] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jae Youn Moon
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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