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Evaluating Effectiveness and Safety in Chronic Kidney Disease with Atrial Flutter Using an Anticoagulation Strategy. ACTA ACUST UNITED AC 2020; 56:medicina56060266. [PMID: 32481685 PMCID: PMC7353883 DOI: 10.3390/medicina56060266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: Recent randomized trials of oral antithrombotic drugs with atrial flutter (AFL) excluded patients with renal impairment because of their increased risk of bleeding. To date, no relevant studies have assessed the effectiveness and safety of different antithrombotic drugs in chronic kidney disease (CKD) patients with AFL. This cohort study evaluated the effectiveness and safety of different antithrombotic drugs in CKD patients with AFL. This study also investigated the risk of cardiovascular events from antithrombotic drugs through different risk profiles of stroke stratified by the CHA2DS2-VASc score. Materials and Methods: This cohort study was performed in patients with AFL and CKD who were extracted from the National Health Insurance (NHI) Database in Taiwan. Oral antithrombotic therapy (oral anticoagulants (OAC) or antiplatelets (APT)) was administered to patients who had been diagnosed with AFL after being diagnosed with CKD between 2011 and 2015. Primary outcomes, including ischemic stroke, systemic embolism, and composite of stroke, and secondary outcomes, including major adverse cardiac events (MACEs), major bleeding, all-cause mortality, and cardiovascular-related death, were examined. Results: A total of 2468 patients were included in this study. The results showed no statistically significant differences in the risk of primary outcomes. For the secondary outcomes, there were also no statistically significant differences in the risk of MACEs and major bleeding. However, the pooled results indicated that the hazard ratio (HR) for all-cause mortality with OAC was 0.24 (95% confidence interval (CI) = 0.10–0.55) compared with combination therapy, and the HR for APT compared with OAC was 2.86 (95% CI = 1.48–5.53). Conclusions: In the studied population, OAC or APT alone were proved equally effective for stroke prophylaxis. Furthermore, OAC might reduce the all-cause mortality rate compared with APT and should be considered as the first choice of oral antithrombotic drugs in patients with AFL and CKD.
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Locham S, Beaulieu RJ, Dakour-Aridi H, Nejim B, Malas MB. Role of antiplatelet therapy in the durability of hemodialysis access. J Nephrol 2018; 31:603-611. [PMID: 29730781 DOI: 10.1007/s40620-018-0490-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/09/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Antiplatelet therapy (APT) is often used on anecdotal grounds to improve vascular access patency. The aim of this study was to assess the role of APT in hemodialysis (HD) patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement. METHODS All patients in a large HD vascular qualitative initiative database (2011-2017) were included and divided into no antiplatelet therapy (no-APT) vs. any APT [aspirin (ASA) or P2Y12 inhibitors (PI)]. Multivariate [logistic (MLR) and Cox (MCR) regression] analyses were used as appropriate. RESULTS A total of 24,847 patients undergoing HD access creation were identified (78% AVF). APT was noted among 49 and 46% of AVG and AVF patients, respectively. In MLR analysis, patients on no-APT vs. APT had a 12-fold increased risk of in-hospital mortality (odds ratio (OR) 11.79, [95% confidence interval 5.30-26.26]) and the risk of developing steal syndrome was higher among patients discharged on APT (OR 1.81, [1.19-2.76]). In patients undergoing AVF, primary patency (PP) was similar between APT and no-APT. However, in patients undergoing AVG, PP rates at 12 months were significantly higher for APT: ASA (47 vs. 41%) and PI (51 vs. 41%) than for no-APT (p = 0.008). At MCR analysis, the loss of PP at 12 months was 13% lower in ASA users (hazard ratio (HR) 0.87, [0.77-0.97], p = 0.02) and 24% lower in PI users (HR 0.76, [0.57-0.99], p = 0.046) compared to no-APT. CONCLUSION In a large national database, we showed that antiplatelet therapy was associated with lower in-hospital mortality. Aspirin and P2Y12-inhibitor use among AVG patients demonstrated improved PP rates compared to no antiplatelet therapy. We recommend the use of antiplatelet therapy especially in patients on AVG.
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Affiliation(s)
- Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | | | - Hanaa Dakour-Aridi
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | - Besma Nejim
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, MD, USA. .,Center for Research Excellence and Clinical Trials, Johns Hopkins Hospital, Baltimore, MD, USA. .,Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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3
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Abstract
Introduction Prosthetic arteriovenous (AV) grafts are indicated in patients with failed AV fistula (AVF), exhausted superficial veins or unsuitable vessels. Increasing the proportion of prevalent hemodialysis (HD) patients using autogenous AVF should reduce the need for AV grafts and associated morbidity. This paper reviews the current role of prosthetic AV grafts in vascular access for HD. Technical considerations Prior to the insertion of a prosthetic AV graft, a comprehensive review of previous access procedures and full physical examination in addition to vessel mapping is required. Anastomotic technique should take into account the flow diffuser concept, graft geometry and an anastomotic angle of 15° in order to reduce the incidence of intimal hyperplasia. Results Many authors report 1 and 2-yr cumulative graft patency rates of 59–90% and 50–82%, respectively. The major drawbacks with synthetic grafts include: thrombosis, a five-fold increase in infection risk and steal syndrome. The choice between surgical and percutaneous methods of dealing with blocked AV grafts remains controversial, though percutaneous techniques are assuming an increasingly important role. Percutaneous strategies are successful in declotting access in 67–95% of cases. Stenting of stenotic lesions following thrombectomy improves secondary patency rates. Strategies for dealing with AV graft infection include antibiotic prophylaxis, partial, subtotal or total graft excision and the use of biological prosthesis. Conclusions Though more prone to complications than autogenous AVFs, AV grafts offer a short maturation period and are more amenable to thrombectomy by radiological or surgical means. Complex AV grafts may be appropriate in patients with exhausted access sites.
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Affiliation(s)
- Jacob A. Akoh
- Surgery & Renal Services Directorate, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth - UK
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Chen YT, Chen HT, Hsu CY, Chao PW, Kuo SC, Ou SM, Shih CJ. Dual Antiplatelet Therapy and Clinical Outcomes after Coronary Drug-Eluting Stent Implantation in Patients on Hemodialysis. Clin J Am Soc Nephrol 2017; 12:262-271. [PMID: 28174317 PMCID: PMC5293329 DOI: 10.2215/cjn.04430416] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 10/19/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to investigate the benefits and risks of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation in patients undergoing hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A nested case-control analysis of patients on hemodialysis after receipt of DES and DAPT treatment was conducted using data from Taiwan's National Health Insurance Research Database for the period 2007-2011. Cases of myocardial infarction or death within 1 year after DES implantation were matched one-to-one with control patients. Odds ratios were calculated to compare DAPT continuation with discontinuation. Additionally, a propensity score-adjusted 6-month landmark cohort analysis was also conducted to evaluate the long-term benefits and risks of prolonged (>6 months) compared with ≤6 months of DAPT use. The primary outcomes were death and myocardial infarction. The secondary outcomes were ischemic stroke, revascularization, and major bleeding. RESULTS In the nested case-control analysis, patients who continued DAPT had a lower rate of death or myocardial infarction within 1 year after receipt of a DES (adjusted odds ratio, 0.54; 95% confidence interval, 0.36 to 0.81; P=0.003), whereas this association became statistically nonsignificant when compared with patients who discontinued DAPT for the period between 6 and 12 months after receipt of a DES (adjusted odds ratio, 1.51; 95% confidence interval, 0.75 to 3.04). In the propensity score-adjusted cohort analysis, >6 months of DAPT use was not associated with different primary or secondary outcomes than shorter-term use. CONCLUSIONS Our findings support that the clinical effectiveness of extended DAPT in a hemodialysis population may be tempered after 6 months post-DES implantation.
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Affiliation(s)
- Yung-Tai Chen
- Divisions of *Nephrology and
- Institute of Clinical Medicine
| | - Hung-Ta Chen
- Endocrinology and Metabolism, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan
- School of Medicine, and
| | - Chien-Yi Hsu
- Institute of Clinical Medicine
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- College of Medicine and
| | - Pei-Wen Chao
- College of Medicine and
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | | | - Shuo-Ming Ou
- Institute of Clinical Medicine
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; and
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McCullough PA, Verrill TA. Cardiorenal Interaction: Appropriate Treatment of Cardiovascular Risk Factors to Improve Outcomes in Chronic Kidney Disease. Postgrad Med 2015; 122:25-34. [DOI: 10.3810/pgm.2010.03.2119] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Tanios BY, Itani HS, Zimmerman DL. Clopidogrel Use in End-Stage Kidney Disease. Semin Dial 2014; 28:276-81. [DOI: 10.1111/sdi.12338] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Bassem Y. Tanios
- Nephrology Department; Paris Sud University; Le Kremlin Bicêtre France
| | - Houssam S. Itani
- Division of Nephrology; Department of Medicine; University of Ottawa; Ottawa Hospital; Ottawa Ontario Canada
| | - Deborah L. Zimmerman
- Division of Nephrology; Department of Medicine; University of Ottawa; Ottawa Hospital; Ottawa Ontario Canada
- Kidney Research Centre of the Ottawa Hospital Research Institute; Ottawa Ontario Canada
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Chen CY, Lee KT, Lee CTC, Lai WT, Huang YB. Effectiveness and Safety of Antiplatelet in Stroke Patients with End-Stage Renal Disease Undergoing Dialysis. Int J Stroke 2014; 9:580-90. [DOI: 10.1111/ijs.12254] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/24/2013] [Indexed: 12/19/2022]
Abstract
Background Antiplatelet therapy is known to decrease the risk of secondary ischemic stroke. However, the effectiveness and safety of antiplatelet therapy in patients with end-stage renal disease are uncertain, especially in dialysis. Aims and/or hypothesis We estimated the effectiveness and safety of antiplatelet drugs (aspirin and clopidogrel) for the prevention of recurrent ischemic stroke in end-stage renal disease patients undergoing dialysis during long-term follow-up after first-time ischemic stroke. Methods The cases were identified from the National Health Insurance Research Database. Antiplatelet therapy was administered for 11 years to patients experiencing a first ischemic stroke between 1998 and 2006. Primary outcomes, including death and readmission to hospital for stroke, and secondary outcomes, including death, stroke, and acute myocardial infarction or bleeding, were examined. Results In total, 1936 patients experienced a first ischemic stroke during the follow-up. In a time-dependent analysis, the hazard ratio for primary outcomes in patients treated with aspirin was 0·671 ( P < 0·001) and that for clopidogrel was 0·933 ( P = 0·497). At secondary outcomes, patients treated with aspirin, hazard ratio for readmission for stroke was 0·715 ( P = 0·002) and that for bleeding was 0·885 ( P = 0·291). Independent risk factors for mortality and readmission due to ischemic stroke included age, diabetes mellitus, and administration of proton pump inhibitors. Conclusions Antiplatelet therapy, especially aspirin, still offers safe and effective treatment for ischemic stroke prevention in patients with end-stage renal disease undergoing dialysis.
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Affiliation(s)
- Chung-Yu Chen
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kun-Tai Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Charles Tzu-Chi Lee
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Ter Lai
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yaw-Bin Huang
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Lin TH, Chuang SY, Chu CY, Lee WH, Hsu PC, Su HM, Li YH, Fang CC, Wang KY, Tseng WK, Li AH, Ueng KC, Hsieh IC, Huang LC, Wang CH, Pan WH, Yeh HI, Wu CC, Yin WH, Chen JW. The impact of chronic kidney disease on lipid management and goal attainment in patients with atherosclerosis diseases in Taiwan. Int J Med Sci 2014; 11:381-8. [PMID: 24578616 PMCID: PMC3936033 DOI: 10.7150/ijms.7069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/15/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) is a very high risk cardiovascular disease population and should be treated aggressively. We investigated lipid management in CKD patients with atherosclerosis in Taiwan. METHODS 3057 patients were enrolled in a multi-center study (T-SPARCLE). Lipid goal are defined as total cholesterol (TC) < 160mg/dl, low-density lipoprotein (LDL) <100 mg/dl, high-density lipoprotein (HDL) > 40 mg/dl in men, HDL > 50 mg/dl in women, non-HDL cholesterol < 130mg/dl, and triglyceride < 150 mg/dl. RESULTS Compared with those without CKD (n=2239), patients with CKD (n=818) had more co-morbidities (hypertension, glucose intolerance, stroke and heart failure) and lower HDL but higher triglyceride levels. Overall 2168 (70.5%) patients received lipid-lowering agents. There was similar equivalent statin potency between CKD and non-CKD groups. The goal attainment is lower in HDL and TG in the CKD group as compared with non-CKD subjects (47.1 vs. 51.9% and 63.2 vs. 68.9% respectively, both p < 0.02). Analysis of sex and CKD interaction on goals attainment showed female CKD subjects had lower non-HDL and TG goals attainment compared with non-CKD males (both p < 0.019). CONCLUSION Although presenting with more comorbidities, the CKD population had suboptimal lipid goal attainment rate as compared with the non-CKD population. Further efforts may be required for better lipid control especially on the female CKD subjects.
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Affiliation(s)
- Tsung-Hsien Lin
- 1. Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- 2. Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shao-Yuan Chuang
- 3. National Health Research Institute, Chunan, and Academia Sinica, Taipei, Taiwan
| | - Chun-Yuan Chu
- 1. Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Hsien Lee
- 1. Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Po-Chao Hsu
- 1. Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- 2. Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ho-Ming Su
- 1. Division of Cardiology, Department of Internal Medicine; Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- 2. Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Heng Li
- 4. Division of Cardiology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ching-Chang Fang
- 5. Division of Cardiology, Tainan Municipal Hospital, Tainan, Taiwan
| | - Kuo-Yang Wang
- 6. Division of Cardiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Kung Tseng
- 7. Division of Cardiology, E-DA Hospital, Kaohsiung, Taiwan
| | - Ai-Hsien Li
- 8. Division of Cardiology, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Kwo-Chang Ueng
- 9. Faculty of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - I-Chang Hsieh
- 10. Division of Cardiology, Linkou Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Lien-Chi Huang
- 11. Division of Cardiology, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan
| | - Chiun-Hsiung Wang
- 12. Division of Cardiology, Taipei City Hospital Renai Branch, Taipei, Taiwan
| | - Wen-Harn Pan
- 3. National Health Research Institute, Chunan, and Academia Sinica, Taipei, Taiwan
| | - Hung-I Yeh
- 13. Department of Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chau-Chung Wu
- 14. Department of Primary Care Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Hsian Yin
- 15. Division of Cardiology, Heart Centre, Cheng-Hsin General Hospital, and Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jaw-Wen Chen
- 16. Division of Cardiology, Taipei Veterans General Hospital, and Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
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Morel O, Muller C, Jesel L, Moulin B, Hannedouche T. Impaired platelet P2Y12 inhibition by thienopyridines in chronic kidney disease: mechanisms, clinical relevance and pharmacological options. Nephrol Dial Transplant 2013; 28:1994-2002. [DOI: 10.1093/ndt/gft027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Muller C, Caillard S, Jesel L, El Ghannudi S, Ohlmann P, Sauleau E, Hannedouche T, Gachet C, Moulin B, Morel O. Association of Estimated GFR With Platelet Inhibition in Patients Treated With Clopidogrel. Am J Kidney Dis 2012; 59:777-85. [DOI: 10.1053/j.ajkd.2011.12.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 12/22/2011] [Indexed: 11/11/2022]
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11
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Alexopoulos D, Xanthopoulou I, Panagiotou A, Komninakis D, Germanos N, Goudas P, Koutroulia E, Fourtounas C. Prevalence of inadequate platelet inhibition by clopidogrel in patients receiving hemodialysis. Am J Kidney Dis 2011; 59:469-71. [PMID: 22154328 DOI: 10.1053/j.ajkd.2011.10.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 11/26/2011] [Indexed: 11/11/2022]
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Alexopoulos D, Panagiotou A, Xanthopoulou I, Komninakis D, Kassimis G, Davlouros P, Fourtounas C, Goumenos D. Antiplatelet effects of prasugrel vs. double clopidogrel in patients on hemodialysis and with high on-treatment platelet reactivity. J Thromb Haemost 2011; 9:2379-85. [PMID: 21985070 DOI: 10.1111/j.1538-7836.2011.04531.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND High on-treatment platelet reactivity (HTPR) is frequent in patients on hemodialysis (HD) receiving clopidrogel. OBJECTIVES The primary aim of this study was to determine the antiplatelet effects of prasugrel vs. high-dose clopidogrel in patients on HD with HTPR. PATIENTS/METHODS We performed a prospective, single-center, single-blind, investigator-initiated, randomized, crossover study to compare platelet inhibition by prasugrel 10 mg day(-1) with that by high-dose 150 mg day(-1) clopidogrel in 21 patients on chronic HD with HTPR. Platelet function was assessed with the VerifyNow assay, and genotyping was performed for CYP2C19*2 carriage. RESULTS The primary endpoint of platelet reactivity (PR, measured in P2Y12 reaction units [PRU]) was lower in patients receiving prasugrel (least squares [LS] estimate 156.6, 95% confidence interval [CI] 132.2-181.1) than in those receiving high-dose clopidogrel (LS 279.9, 95% CI 255.4-304.3), P < 0.001). The LS mean differences between the two treatments were - 113.4 PRU (95% CI - 152.9 to - 73.8, P < 0.001) and - 163.8 PRU (95% CI - 218.1 to - 109.2, P < 0.001) in non-carriers and carriers of at least one CYP2C19*2 allele, respectively. HTPR rates were lower for prasugrel than clopidogrel, in all patients (19% vs. 85.7%, P < 0.001) and in non-carriers (25.7% vs. 80%, P = 0.003). All carriers continued to show HTPR while receiving high-dose clopidogrel, but none showed it while receiving prasugrel. CONCLUSIONS In HD patients exhibiting HTPR following standard clopidogrel treatment, prasugrel 10 mg day(-1) is significantly more efficient than doubling the clopidogrel dosage in achieving adequate platelet inhibition. Neither effect seems to be influenced by carriage of the loss-of-function CYP2C19*2 allele.
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Affiliation(s)
- D Alexopoulos
- Department of Cardiology, Patras University Hospital, Patras, Greece.
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Affiliation(s)
- Graham F Smith
- Central Chemistry Team Lead, Merck Research Laboratories, Boston, 33 Avenue Louis Pasteur, Boston, MA 02115, USA
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Cardiovascular Mortality in Chronic Kidney Disease Patients Undergoing Percutaneous Coronary Intervention Is Mainly Related to Impaired P2Y12 Inhibition by Clopidogrel. J Am Coll Cardiol 2011; 57:399-408. [DOI: 10.1016/j.jacc.2010.09.032] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 09/08/2010] [Accepted: 09/28/2010] [Indexed: 12/20/2022]
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Badland M, Compère D, Courté K, Dublanchet AC, Blais S, Manage A, Peron G, Wrigglesworth R. Thiophene and bioisostere derivatives as new MMP12 inhibitors. Bioorg Med Chem Lett 2011; 21:528-30. [PMID: 21111619 DOI: 10.1016/j.bmcl.2010.10.087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 10/15/2010] [Accepted: 10/16/2010] [Indexed: 10/18/2022]
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Low responsiveness to thienopyridine in hemodialysis patients. Cardiovasc Interv Ther 2009; 25:18-23. [PMID: 24122428 DOI: 10.1007/s12928-009-0002-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 07/27/2009] [Indexed: 01/23/2023]
Abstract
We sought to evaluate whether thienopyridine low responsiveness, a predictor of stent thrombosis, is found in hemodialysis patients. We measured platelet aggregation at the site of implantation of drug-eluting stents in 333 patients with angina pectoris undergoing dual anti-platelet therapy. Thirty-one patients were on hemodialysis (HD group), and 302 were not (N-HD group). We used a novel whole-blood aggregometer. The aggregometer used the screen filtration method, with adenosine diphosphate as an agonist. The concentration of agonist required to induce 50% of the maximum pressure rate was calculated and indicated as the platelet aggregatory threshold index (PATI). Low responsiveness for thienopyridine was defined if the PATI levels were <4 μmol/l. PATI levels (μmol/l) were significantly lower in the HD group than in the N-HD group (6.8 ± 4.8 vs. 9.1 ± 5.4, P = 0.023), and the rate of low responsiveness for thienopyridine was significantly higher in the HD group than in the N-HD group (45.7 vs. 26.8%, P = 0.019). Non-fatal myocardial infarction and stent thrombosis occurred in three of the HD group and in nine of the N-HD group (P = 0.122). Late stent thrombosis occurred at a significantly higher rate in the HD group than in the N-HD group (P = 0.002). The rate of target lesion revascularization was significantly higher in the HD group than in the N-HD group (38 vs. 11.8%, P = 0.0001). In conclusion, low responsiveness to thienopyridine, as an indicator of platelet reactivity, is found more frequently in hemodialysis patients.
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Notaro LA, Usman MH, Burke JF, Siddiqui A, Superdock KR, Ezekowitz MD. Secondary Prevention in Concurrent Coronary Artery, Cerebrovascular, and Chronic Kidney Disease: Focus on Pharmacological Therapy. Cardiovasc Ther 2009; 27:199-215. [DOI: 10.1111/j.1755-5922.2009.00087.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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18
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El-Menyar A, Hussein H, Al Suwaidi J. Coronary stent thrombosis in patients with chronic renal insufficiency. Angiology 2009; 61:297-303. [PMID: 19689994 DOI: 10.1177/0003319709344574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renal insufficiency (RI) is a strong predictor of unfavorable outcomes after percutaneous coronary intervention (PCI). After PCI, stent thrombosis (ST) is a considerable concern. The risk of ST in RI has not been independently evaluated before. The mechanism of ST is frequently related to dual antiplatelet underuse. We reviewed the publications listed on Medline, Scopus, and EBSCO Host research database in the last two decades to identify the risk of ST in patients with RI. There are no enough data on the incidence of ST in RI patients. Platelet reactivity, appropriate period of dual antiplatelet therapy, coronary anatomy, selection of stent, and patient compliance are vital issues that warrant detailed evaluation in RI patients. Moreover, prospective trials and new therapeutic strategies are needed for proper assessment and management of ST in high-risk patients.
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Affiliation(s)
- Ayman El-Menyar
- Department of Cardiology and Cardiovascular Surgery, Hamad General Hospital, HMC, Doha, Qatar.
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Małek LA, Bilińska ZT, Sitkiewicz D, Kłopotowski M, Witkowski A, Ruzyłło W. Platelet reactivity on aspirin, clopidogrel and abciximab in patients with acute coronary syndromes and reduced estimated glomerular filtration rate. Thromb Res 2009; 125:67-71. [PMID: 19443019 DOI: 10.1016/j.thromres.2009.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2009] [Revised: 03/07/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Lukasz A Małek
- 1st Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland.
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Washam JB, Adams GL. Risks and benefits of antiplatelet therapy in uremic patients. Adv Chronic Kidney Dis 2008; 15:370-7. [PMID: 18805383 DOI: 10.1053/j.ackd.2008.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with renal insufficiency are at an increased risk for cardiovascular morbidity and mortality. Despite being at a substantial risk for thrombotic events, patients with renal insufficiency also experience a greater number of hemorrhagic complications associated with antiplatelet therapy than individuals with normal renal function. This review focuses on the benefits and risks of antiplatelet therapy in patients with impaired kidney function suffering from an acute coronary syndrome.
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Best PJ, Steinhubl SR, Berger PB, Dasgupta A, Brennan DM, Szczech LA, Califf RM, Topol EJ. The efficacy and safety of short- and long-term dual antiplatelet therapy in patients with mild or moderate chronic kidney disease: results from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial. Am Heart J 2008; 155:687-93. [PMID: 18371477 DOI: 10.1016/j.ahj.2007.10.046] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2006] [Accepted: 10/31/2007] [Indexed: 01/21/2023]
Abstract
BACKGROUND Mild and moderate chronic kidney disease (CKD) is associated with decreased survival and increased adverse events after a percutaneous coronary intervention (PCI). Therapy with clopidogrel decreases adverse events in large patient populations. Therefore, we sought to determine the efficacy and safety of long-term clopidogrel therapy in patients with CKD. METHODS Two thousand two patients from the CREDO trial in whom an elective PCI of a single or multiple vessels was planned were analyzed. Patients were randomly assigned to a 300-mg loading dose of clopidogrel before PCI followed by clopidogrel 75 mg/d for a year versus a placebo loading dose at the time of the PCI procedure and clopidogrel 75 mg/d for 28 days and placebo for the remainder of a year. Patients were categorized by their estimated creatinine clearance (>90 [normal, n = 999], 60-89 [mild CKD, n = 672], <60 mL/min [moderate CKD, n = 331]). RESULTS Diminished renal function was associated with worse outcomes. Patients with normal renal function who received 1 year of clopidogrel had a marked reduction in death, myocardial infarction, or stroke compared with those who received placebo (10.4% vs 4.4%, P < .001), whereas patients with mild and moderate CKD did not have a significant difference in outcomes with clopidogrel therapy versus placebo (mild: 12.8% vs 10.3%, P = .30; moderate: 13.1% vs 17.8%, P = .24). Clopidogrel use was associated with an increased relative risk of major or minor bleeding, but this increased risk was not different based on renal function (relative risk 1.2, 1.3, 1.1). CONCLUSIONS Clopidogrel in mild or moderate CKD patients may not have the same beneficial effect as it does in patients with normal renal function, but was not associated with a greater relative risk of bleeding based on renal function. Further studies are needed to define the role of clopidogrel therapy in patients with CKD.
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Trimarchi H, Young P, Forrester M, Schropp J, Pereyra H, Freixas E. Clopidogrel diminishes hemodialysis access graft thrombosis. J Vasc Access 2006; 6:29-33. [PMID: 16552680 DOI: 10.1177/112972980500600107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The most common complication of hemodialysis access graft is thrombosis. Clopidogrel, an inhibitor of platelet aggregation, was assessed to prevent this serious complication. METHODS Nineteen patients on chronic hemodialysis whose vascular accesses were grafts were divided into two groups: Group A (n=11, 58%) consisted of patients who did not receive anti-thrombotic therapy after graft placement; Group B (n=8, 42%) received clopidogrel 75 mg/day from two days after surgery onwards. Both groups were well matched with respect to age, gender, cause of renal failure, hematocrit, platelet count and Kt/V. All patients' thrombotic episodes were followed up from the day of graft surgery until thrombosis was diagnosed. Finally, the survival difference between both groups was determined. RESULTS Ten thrombotic episodes were diagnosed in Group A while no events were reported in Group B (p<0.001). Graft access days of patency were significantly more in Group B than in Group A (350.8+/-166 vs 86.8+/-69, p<0.001). The time elapsed from dialysis initiation to graft placement was not different (Group A: 18+/-12 days; Group B: 20+/-10 days). Days in hemodialysis were different between both groups (Group A: 195.9+/-96; Group B: 545.5+/-291, p<0.001) and all patients of Group A (n=11, 57.9%) and two patients of Group B (25%) died (p=0.001). No major bleeding events were reported. CONCLUSIONS Clopidogrel significantly decreased thrombotic graft episodes. Patients on clopidogrel had a prolonged vascular access patency, longer time on hemodialysis and longer survival.
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Affiliation(s)
- H Trimarchi
- Nephrology Section, Department of Medicine, Hospital Británico de Buenos Aires, Argentina.
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23
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Williams ME. Coronary Revascularization in Diabetic Chronic Kidney Disease/End-Stage Renal Disease: A Nephrologist’s Perspective. Clin J Am Soc Nephrol 2006; 1:209-20. [PMID: 17699209 DOI: 10.2215/cjn.00510705] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Mark E Williams
- Renal Unit, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215, USA.
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Trimarchi H, Young P, Forrester M, Schropp J, Pereyra H, Freixas E. Clopidogrel Diminishes Hemodialysis Access Graft Thrombosis. ACTA ACUST UNITED AC 2005; 102:c128-32. [PMID: 16282697 DOI: 10.1159/000089671] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Accepted: 07/21/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND The most common complication of hemodialysis (HD) access graft is thrombosis. Clopidogrel, an inhibitor of platelet aggregation, was assessed to prevent this serious complication. METHODS A prospective study in which 24 patients on chronic HD whose vascular accesses were grafts were divided into two groups: group A (n = 12, 50%) consisted of patients who did not receive antithrombotic therapy after graft creation, and group B (n = 12, 50%) received clopidogrel 75 mg/day from 2 days after surgery onwards. Both groups were not different according to age, gender, cause of renal failure, hematocrit levels, platelet counts and Kt/V. All patients' thrombotic episodes were followed up from the day of graft surgery until thrombosis was diagnosed. Finally, the patient survival difference between both groups was determined. RESULTS Eleven thrombotic episodes were diagnosed in group A while one event was reported in group B (p < 0.001). Graft access days of patency were significantly longer in group B compared to group A (380.8 +/- 170 vs. 90.1 +/- 57.2, p < 0.001). Time that elapsed from dialysis initiation to graft creation was not different (group A 18 +/- 12 days, group B 20 +/- 10 days). Days on HD were different between both groups (group A 208.9 +/- 97.2 vs. group B 583.2 +/- 287.0, p < 0.001) and all patients from group A (n = 12, 100%) and 2 patients from group B (16.7%) died (p = 0.001). Major bleeding events were not reported. CONCLUSIONS Clopidogrel significantly decreased thrombotic graft episodes. Patients on clopidogrel had a prolonged vascular access patency, longer time on HD and better survival.
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Affiliation(s)
- Hernán Trimarchi
- Department of Medicine, Hospital Británico, Buenos Aires, Argentina.
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25
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O'Hanlon R, Reddan DN. Treatment of acute coronary syndromes in patients who have chronic kidney disease. Med Clin North Am 2005; 89:563-85. [PMID: 15755468 DOI: 10.1016/j.mcna.2004.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients with CKD and CAD have traditionally been a difficult population to diagnose and treat in the setting of ACS. In addition to having poorer outcomes post-ACS, data are lacking regarding best treatments available. Aggressive interventional and medical treatments in this group with already poor outcomes are not necessarily contraindicated and should always be considered. The appalling outcome for CKD patients post-ACS is improved by many therapies shown to benefit in the non-CKD patients. Data suggest that troponins are useful markers in CKD patients, that major bleeding is not increased with the use of GP IIb-IIIa antagonists, that thrombolytics have been used successfully in CKD patients, and that PCI electively and as a primary treatment for ACS is successful and probably more beneficial to treatment.
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Affiliation(s)
- Rory O'Hanlon
- Division of Cardiology, University College Galway Hospital, Galway, Ireland
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26
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McCullough PA. Cardiovascular disease in chronic kidney disease from a cardiologist's perspective. Curr Opin Nephrol Hypertens 2005; 13:591-600. [PMID: 15483448 DOI: 10.1097/00041552-200411000-00003] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease accounts for the majority of morbidity and mortality in patients with chronic kidney disease (CKD). This review therefore concentrates on CKD from the viewpoint of the cardiologist. RECENT FINDINGS Studies have identified several explanations for this observation, including high rates of risk factors for cardiovascular disease, lesser use of cardioprotective strategies, adverse outcomes with cardiovascular drugs and procedures, and accelerated atherosclerosis and myocardial disease in CKD. Because recent studies have rigorously controlled for confounding factors, there is an emerging recognition that CKD is an independent cardiovascular risk state. Conversely, CKD appears to be the result of systemic atherosclerosis. The relative under-utilization of cardioprotective therapies has been an increasingly reported finding in the literature. It appears that conventional cardiovascular risk factor reduction in both the chronic and acute care settings has a greater relative benefit in those patients with CKD than in those with normal renal function. SUMMARY CKD is an independent cardiovascular risk state. Hence, there is a strong rationale for research in CKD patients into the pathogenesis of CVD. In addition, there are multiple opportunities for improving cardiovascular outcomes in patients with CKD, including both chronic and acute cardiovascular risk reduction.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Divisions of Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, 4949 Coolidge Highway, Royal Oak, MI 48073, USA.
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27
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McCullough PA. Opportunities for improvement in the cardiovascular care of patients with end-stage renal disease. Adv Chronic Kidney Dis 2004; 11:294-303. [PMID: 15241743 DOI: 10.1053/j.arrt.2004.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease accounts for the majority of morbidity and mortality in patients with end-stage renal disease (ESRD). Studies have identified several explanations for this observation, such as high rates of cardiovascular risk factors, lesser use of cardioprotective strategies, adverse outcomes with cardiovascular drugs and procedures, and accelerated atherosclerosis and myocardial disease in ESRD. Based on these findings, this article addresses the critical opportunities for improvement in cardiovascular outcomes in patients with ESRD. These improvements include prevention of cardiovascular events, management of acute coronary syndromes and heart failure, and the prevention of sudden death.
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Affiliation(s)
- Peter A McCullough
- Department of Medicine, Division of Cardiology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Mobley JE, Bresee SJ, Wortham DC, Craft RM, Snider CC, Carroll RC. Frequency of nonresponse antiplatelet activity of clopidogrel during pretreatment for cardiac catheterization. Am J Cardiol 2004; 93:456-8. [PMID: 14969622 DOI: 10.1016/j.amjcard.2003.10.042] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2003] [Revised: 10/16/2003] [Accepted: 10/16/2003] [Indexed: 11/20/2022]
Abstract
Platelet function was evaluated before and after clopidogrel therapy in 50 cardiology candidates scheduled for intervention; results were averaged from optical platelet aggregation with 2 significantly correlated point-of-care instruments, Thrombelastograph and Ichor PlateletWorks. Although this was a limited study with few complications, the failure of clopidogrel therapy (30% nonresponders with <10% average platelet inhibition) was not correlated with clinical pretreatment variables, including atorvastatin therapy, postintervention bleeding complications, or major adverse coronary events.
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Affiliation(s)
- Joseph E Mobley
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee 37920, USA
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Rodgers JE, Steinhubl SR. Clopidogrel’s role in the management of atherosclerotic disease: a focus on acute coronary syndromes. Expert Rev Cardiovasc Ther 2003; 1:507-21. [PMID: 15030250 DOI: 10.1586/14779072.1.4.507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent advances in our understanding of the role of the platelet in the atherosclerotic process beyond the acute formation of arterial blood clots, such as inflammation, have highlighted the role of antiplatelet agents as being much more than just 'blood thinners.' Some of the most important cardiovascular trials performed in the last 20 years have studied antiplatelet therapies. However, despite their long history, current global health implications and proven benefit, there remain substantial gaps in our understanding as to how to best utilize the limited number of antiplatelet agents available. This article will discuss the mechanism of action of the antiplatelet class known as thienopyridines, the pharmacodynamics and pharmacokinetics of the thienopyridine agent clopidogrel (Plavix, Bristol-Myers Squibb and Sanofi Pharmaceuticals) as well as the literature supporting its clinical benefits and areas of ongoing research that will help clarify the optimal utilization of clopidogrel for the treatment of cardiovascular disease.
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Affiliation(s)
- Jo E Rodgers
- Division of Pharmacotherapy, University of North Carolina, Chapel Hill 27599-7360, USA.
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30
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Fernandez JS, Sadaniantz BT, Sadaniantz A. Review of antithrombotic agents used for acute coronary syndromes in renal patients. Am J Kidney Dis 2003; 42:446-55. [PMID: 12955672 DOI: 10.1016/s0272-6386(03)00800-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Management issues in acute coronary syndromes (ACSs) with regard to patients with renal insufficiency or failure are complex. Renal patients have a greater risk for bleeding compared with those with normal renal function because of prolonged bleeding time and platelet dysfunction. Some of the drugs used have significant renal excretion, such as the glycoprotein IIb/IIIa receptor antagonists. Additionally, thrombolytics are underused, which contributes to the delay in instituting immediate treatment of acute myocardial infarction. Clinical data regarding the optimum management of ACSs in renal patients are still lacking. In this article, we review the available data on the use of antithrombotic agents, particularly in patients with renal impairment.
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Affiliation(s)
- Jocelyn S Fernandez
- The Miriam Hospital Division of Cardiology, Brown University School of Medicine, Providence, RI 02906, USA
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31
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Kaufman JS, O'Connor TZ, Zhang JH, Cronin RE, Fiore LD, Ganz MB, Goldfarb DS, Peduzzi PN. Randomized controlled trial of clopidogrel plus aspirin to prevent hemodialysis access graft thrombosis. J Am Soc Nephrol 2003; 14:2313-21. [PMID: 12937308 DOI: 10.1097/01.asn.0000081661.10246.33] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Thrombosis of hemodialysis vascular access grafts represents a major medical and economic burden. Experimental and clinical models suggest a role for antiplatelet agents in the prevention of thrombosis. The study was designed to determine the efficacy of the combination of aspirin and clopidogrel in the prevention of graft thrombosis. The study was a randomized, double-blind trial conducted at 30 hemodialysis units at Veterans Affairs medical centers. Participants undergoing hemodialysis with a polytetrafluoroethylene graft in the arm were randomized to receive either double placebos or aspirin (325 mg) and clopidogrel (75 mg) daily. Participants were to be monitored while receiving study medications for a minimum of 2 yr. The study was stopped after randomization of 200 participants, as recommended by the Data Safety and Monitoring Board because of a significantly increased risk of bleeding among the participants receiving aspirin and clopidogrel therapy. The cumulative incidence of bleeding events was significantly greater for those participants, compared with participants receiving placebos [hazard ratio, 1.98; 95% confidence interval (CI), 1.19 to 3.28; P = 0.007]. Twenty-three participants in the placebo group and 44 participants in the active treatment group experienced a bleeding event (P = 0.006). There was no significant benefit of active treatment in the prevention of thrombosis (hazard ratio, 0.81; 95% CI, 0.47 to 1.40; P = 0.45), although there was a trend toward a benefit among participants who had not experienced previous graft thrombosis (hazard ratio, 0.52; 95% CI, 0.22 to 1.26; P = 0.14). In the hemodialysis population, therapy with aspirin and clopidogrel was associated with a significantly increased risk of bleeding and probably would not result in a reduced frequency of graft thrombosis.
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Affiliation(s)
- James S Kaufman
- Department of Veterans Affairs Boston Healthcare System and Department of Medicine, Boston University School of Medicine, Boston, Massachusetts 02130, USA.
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32
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Murphy SW. Management of heart failure and coronary artery disease in patients with chronic kidney disease. Semin Dial 2003; 16:165-72. [PMID: 12641882 DOI: 10.1046/j.1525-139x.2003.16033.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiovascular disease (CVD) is a major contributor to the mortality and morbidity of patients who suffer from chronic kidney disease (CKD). Heart failure and ischemic heart disease (IHD) are both highly prevalent in this population. The diagnosis of myocardial dysfunction is usually based on echocardiography. As in the general population, systolic dysfunction is treated with a combination of diuretics, renin-angiotensin system blockade, and beta-receptor antagonists. Diastolic dysfunction is best managed by eliminating the cause. Non-invasive tests for coronary artery disease (CAD) may be less reliable in patients with renal disease compared with nonuremic patients. Medical therapy of IHD in this population is generally similar to that for other patient groups, but surgical revascularization appears to carry a higher risk of complications with poorer clinical outcomes. The choice of revascularization procedure (coronary artery bypass grafting versus percutaneous transluminal angioplasty) should be based on the specific coronary anatomy of a given patient as well as a consideration of other comorbid factors.
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Affiliation(s)
- Sean W Murphy
- Department of Medicine, Division of Nephrology, Memorial University of Newfoundland, St. John's, Canada.
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Abstract
Cardiovascular disease is a major challenge to nephrologists, whether we deal with patients with pre-end-stage renal failure, on dialysis or after successful renal transplantation. It is the most common cause for death in patients with a functional allograft, and prevents many dialysis patients from being engrafted. Coronary artery disease is a diagnostic and therapeutic challenge, as it differs in some respects from that seen in non-uremic cohorts, and lacks much of the evidence-base on which therapeutic intervention rests. This review examines the experimental and clinical literature on cardiovascular disease in uremia, focusing on coronary artery disease. We focus on the incidence, presenting syndromes, screening tools, and interventions in the context of acute and chronic coronary syndromes. Recent evidence comparing coronary angioplasty, coronary artery stenting, and bypass surgery in subjects with renal failure is also reviewed. Coronary artery disease is more prevalent in uremia, more difficult to diagnose and less rewarding to treat compared to non-uremic subjects. Many more randomized trials are needed. In the absence of information from such trials, we advocate aggressive control of conventional and novel cardiovascular risk factors, and early intervention for symptomatic coronary disease.
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Affiliation(s)
- D J Goldsmith
- Renal Unit, Guy's Hospital, London, England, United Kingdom.
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