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Shi L, Chen L, Tian W, Zhao S. Intracoronary Versus Intravenous Low-Dose Tirofiban in Patients With ST-Elevation Myocardial Infarction: A Meta-Analysis of Randomised Controlled Trials. Heart Lung Circ 2024:S1443-9506(24)00628-0. [PMID: 38960752 DOI: 10.1016/j.hlc.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 03/14/2024] [Accepted: 05/09/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND This meta-analysis aimed to evaluate the effects of intracoronary (IC) low-dose tirofiban versus intravenous (IV) administration on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). METHODS All published randomised controlled trials (RCTs) comparing the effects of IC low-dose tirofiban (a bolus of ≤10 ug/kg) versus IV administration in patients with STEMI were identified by searching PubMed, EMBASE, Cochrane Library, and ISI Web of Science from inception to June 2023, with no language restriction. The risk ratio (RR) with 95% confidence intervals (CI) and the weighted mean difference (WMD) with 95% CI were calculated. RESULTS Eleven RCTs involving 1,802 patients were included. Compared with the IV group, IC low-dose tirofiban was associated with improved major adverse cardiac events rate (RR 0.595, 95% CI 0.442-0.802; p=0.001), left ventricular ejection fraction (WMD 1.982, 95% CI 0.565-3.398; p=0.006), thrombolysis in myocardial infarction (TIMI) flow grade (RR 1.065, 95% CI 1.004-1.131; p=0.037), and TIMI myocardial perfusion grade (RR 1.194, 95% CI 1.001-1.425; p=0.049). The two groups had no significant difference in bleeding events (RR 0.952, 95% CI 0.709-1.279; p=0.745). CONCLUSIONS Intracoronary low-dose tirofiban administration may be a safe and effective alternative to IV administration in STEMI patients.
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Affiliation(s)
- Liye Shi
- Department of Geriatric Cardiology, First Hospital of China Medical University, Shenyang, China
| | - Ling Chen
- Department of Geriatric Cardiology, First Hospital of China Medical University, Shenyang, China
| | - Wen Tian
- Department of Geriatric Cardiology, First Hospital of China Medical University, Shenyang, China
| | - Shijie Zhao
- Department of Geriatric Cardiology, First Hospital of China Medical University, Shenyang, China.
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2
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Hasanpour M, Maleki S, Rezaee H, Aminzadeh B, Abbasi Shaye Z, Keykhosravi E. Glycoprotein IIb/IIIa inhibitors in the treatment of thromboembolic events related to endovascular treatment of cerebral aneurysms-systematic review and meta-analysis. Neuroradiol J 2024; 37:152-163. [PMID: 36961079 PMCID: PMC10973825 DOI: 10.1177/19714009231166090] [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] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND AND AIMS Thromboembolism complication is considered the most common complication associated with the treatment of endovascular. This systematic review and meta-analysis aimed to assess the studies investigating the effect of glycoprotein IIb/IIIa inhibitor agents on thromboembolic complications during endovascular aneurysm coiling. MATERIALS AND METHODS This systematic review investigated the outcome of the use of three glycoprotein IIb/IIIa inhibitor agents (ie abciximab, tirofiban, and eptifibatide) on the thromboembolic complications during endovascular aneurysm coiling. The electronic databases of PubMed, Web of Science, Scopus, and Medline were searched up to 25 June 2021, using the keywords "Abciximab," "Tirofiban," and "Eptifibatide" incombination with "Thromboembolism Complication," "Aneurysms," and "Endovascular Aneurysm Coiling." RESULTS A total of 21 articles were found to be eligible and included in this review. The rates of complete and partial recanalization were estimated to be 56% and 92% in patients who underwent abciximab and tirofiban therapy, respectively. Rupture aneurysms were found in the majority of patients. In general, the mortality rate of the patients treated for thromboembolic complications during endovascular treatment of cerebral aneurysms with glycoprotein IIb/IIIa inhibitors was found to be 4.8% (CI 95%:0.027-0.067; p < .005). The average remission rate in studies investigating thromboembolism was 91% (CI 95%:0.88-0.95, I2 : 65.65/p < .001). CONCLUSION Based on the obtained results, a higher mean rate of complete recanalization by eptifibatide was found in studies in which abciximab or tirofiban were used, compared to other mentioned agents. Moreover, the amount of hemorrhage was reported to be less after using tirofiban rather than abciximab.
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Affiliation(s)
- Mohammad Hasanpour
- Division of Vascular and Endoovascular Neurosurgery, Firoozgar Hospital, Faculty of medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Samane Maleki
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Rezaee
- Department of Neurosurgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad Aminzadeh
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Abbasi Shaye
- Akbar Clinical research and Development Unit, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Department of Neurosurgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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3
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Wang J, Zou D. Tirofiban-induced thrombocytopenia. Ann Med 2023; 55:2233425. [PMID: 37439782 PMCID: PMC10348023 DOI: 10.1080/07853890.2023.2233425] [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: 09/05/2022] [Revised: 06/15/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023] Open
Abstract
Tirofiban is a small non-peptide ligand-mimetic Glycoprotein (GP) IIb/IIIa inhibitor which can reversibly bind to the arginine-glycine-aspartic acid (RGD) recognition site of GP IIb/IIIa to prevent platelet aggregation. It reduces the incidence of thrombotic cardiovascular events in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Although generally considered safe, tirofiban has been reported to be associated with thrombocytopenia in several case reports and clinical trials. The pathogenesis for this adverse reaction is not entirely understood, is thought to be due to immune-mediated reaction. This side effect caused by tirofiban is especially concerning given how frequently it is used in the practice of contemporary cardiovascular care. The present review provides an overview of the pathophysiology, clinical presentation, management, and risk factors associated with tirofiban-induced thrombocytopenia.
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Affiliation(s)
- Jun Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Dongna Zou
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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4
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Meyer BM, Campos JK, Collard de Beaufort JC, Chen I, Khan MW, Amin G, Zarrin DA, Lien BV, Coon AL. Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms. Biomedicines 2023; 11:2234. [PMID: 37626730 PMCID: PMC10452183 DOI: 10.3390/biomedicines11082234] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
The use of periprocedural dual antiplatelet therapy (DAPT) has significantly evolved along with innovations in the endovascular management of intracranial aneurysms. Historically, aspirin and clopidogrel have been the most commonly employed regimen due to its safety and efficacy. However, recent studies highlight the importance of tailoring DAPT regimens to individual patient characteristics which may affect clopidogrel metabolism, such as genetic polymorphisms. In the present report, a systematic review of the literature was performed to determine optimal antiplatelet use with flow diverting stents, intracranial stents, intrasaccular devices, and stent-assisted coiling. Studies were analyzed for the number of aneurysms treated, DAPT regimen, and any thromboembolic complications. Based on inclusion criteria, 368 studies were selected, which revealed the increasing popularity of alternative DAPT regimens with the aforementioned devices. Thromboembolic or hemorrhagic complications associated with antiplatelet medications were similar across all medications. DAPT with ticagrelor, tirofiban, or prasugrel are effective and safe alternatives to clopidogrel and do not require enzymatic activation. Further clinical trials are needed to evaluate different antiplatelet regimens with various devices to establish highest-level evidence-based guidelines and recommendations.
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Affiliation(s)
| | - Jessica K. Campos
- Department of Neurological Surgery, University of California Irvine, Orange, CA 92868, USA
| | | | - Ivette Chen
- Harvard University, Cambridge, MA 02138, USA
| | - Muhammad Waqas Khan
- Carondelet Neurological Institute, St. Joseph’s Hospital, Tucson, AZ 85711, USA
| | - Gizal Amin
- Carondelet Neurological Institute, St. Joseph’s Hospital, Tucson, AZ 85711, USA
| | - David A. Zarrin
- School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Brian V. Lien
- Department of Neurological Surgery, University of California Irvine, Orange, CA 92868, USA
| | - Alexander L. Coon
- Carondelet Neurological Institute, St. Joseph’s Hospital, Tucson, AZ 85711, USA
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5
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Tian R, Liu R, Zhang J, Li Y, Wei S, Xu F, Li X, Li C. Efficacy and safety of intracoronary versus intravenous tirofiban in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Heliyon 2023; 9:e15842. [PMID: 37180928 PMCID: PMC10172923 DOI: 10.1016/j.heliyon.2023.e15842] [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: 12/13/2022] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Background Effective antiplatelet therapy is critical for patients with ST-segment elevation myocardial infarction (STEMI) and receiving primary percutaneous coronary interventions (PPCI). Intracoronary (IC) and intravenous (IV) administration of tirofiban are commonly used during the procedure of PPCI. However, which is the better administration route of tirofiban have not been fully evaluated. Methods A comprehensive literature search of RCTs that comparing IC with IV tirofiban in STEMI patients undergoing PPCI was conducted, which were published as of May 7, 2022, in PubMed, Embase, Cochrane Library, Web of Science, Scopus and ClinicalTrials.gov. The primary efficacy endpoint was 30-day major adverse cardiovascular events (MACE) and the primary safety endpoint was in-hospital bleeding events. Results This meta-analysis included 9 trials involving 1177 patients. IC tirofiban significantly reduced the incidence of 30-day MACE (RR 0.65, 95% CI: 0.44 to 0.95, P = 0.028) and improved the rate of the thrombolysis in myocardial infarction (TIMI) grade 3 flow in high-dose (25 μg/kg) group (RR = 1.13, 95% CI: 0.99-1.30, P = 0.001), in-hospital (WMD 2.03, 95% CI: 1.03 to 3.02, P < 0.001), and 6-month left ventricular injection fraction (LVEF) (WMD 6.01, 95% CI: 5.02 to 6.99, P < 0.001) compared with IV. There was no significant difference in the incidences of in-hospital bleeding events (RR 0.96, 95% CI: 0.67 to 1.38, P = 0.82) and thrombocytopenia (RR 0.63, 95% CI: 0.26 to 1.57, P = 0.32) between the two groups. Conclusions IC tirofiban significantly improved the incidence of TIMI 3 in the high-dose group, in-hospital and 6-month LVEF, and reduced the 30-day MACE incidence without increasing the risk of bleeding compared with IV.
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Affiliation(s)
- Rui Tian
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Rugang Liu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jiajun Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yong Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shujian Wei
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaoxing Li
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Chuanbao Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital of Shandong University, Jinan, Shandong, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Sookezian A, Molander GA. Photoinduced Vicinal 1,2-Difunctionalization of Olefins for the Synthesis of Alkyl Sulfonamides. Org Lett 2023; 25:1014-1019. [PMID: 36745531 DOI: 10.1021/acs.orglett.3c00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Alkyl sulfonamides are an important class of bioactive molecules. Historical syntheses have relied on multistep sequences incorporating harsh reaction conditions. Photochemical methods have been limited to hydrosulfamoylation, installing only one substituent across an olefin. Herein, radical/polar crossover (RPC) is used to establish the first multicomponent 1,2-difunctionalization reaction incorporating a sulfonamide moiety and a second reaction partner. This protocol, exemplified on a range of olefins, utilizes various commercial sulfamoyl chlorides and organotrifluoroborates as coupling partners.
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Affiliation(s)
- Anasheh Sookezian
- Roy and Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, 231 South 34th Street, Philadelphia, Pennsylvania 19104-6323, United States
| | - Gary A Molander
- Roy and Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, 231 South 34th Street, Philadelphia, Pennsylvania 19104-6323, United States
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7
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An Updated Review on Glycoprotein IIb/IIIa Inhibitors as Antiplatelet Agents: Basic and Clinical Perspectives. High Blood Press Cardiovasc Prev 2023; 30:93-107. [PMID: 36637623 DOI: 10.1007/s40292-023-00562-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/09/2023] [Indexed: 01/14/2023] Open
Abstract
The glycoprotein (GP) IIb/IIIa receptor is found integrin present in platelet aggregations. GP IIb/IIIa antagonists interfere with platelet cross-linking and platelet-derived thrombus formation through the competition with fibrinogen and von Willebrand factor. Currently, three parenteral GP IIb/IIIa competitors (tirofiban, eptifibatide, and abciximab) are approved for clinical use in patients affected by percutaneous coronary interventions (PCI) in the location of acute coronary syndrome (ACS). GP IIb/IIIa antagonists have their mechanism of action in platelet aggregation prevention, distal thromboembolism, and thrombus formation, whereas the initial platelet binding to damage vascular areas is preserved. This work is aimed to provide a comprehensive review of the significance of GP IIb/IIIa inhibitors as a sort of antiplatelet agent. Their mechanism of action is based on factors that affect their efficacy. On the other hand, drugs that inhibit GP IIb/IIIa already approved by the FDA were reviewed in detail. Results from major clinical trials and regulatory practices and guidelines to deal with GP IIb/IIIa inhibitors were deeply investigated. The cardiovascular pathology and neuro-interventional surgical application of GP IIb/IIIa inhibitors as a class of antiplatelet agents were developed in detail. The therapeutic risk/benefit balance of currently available GP IIb/IIa receptor antagonists is not yet well elucidated in patients with ACS who are not clinically evaluated regularly for early cardiovascular revascularization. On the other hand, in patients who have benefited from PCI, the antiplatelet therapy intensification by the addition of a GP IIb/IIIa receptor antagonist (intravenously) may be an appropriate therapeutic strategy in reducing the occurrence of risks of thrombotic complications related to the intervention. Development of GP IIb/IIIa inhibitors with oral administration has the potential to include short-term antiplatelet benefits compared with intravenous GP IIb/IIIa inhibitors for long-term secondary preventive therapy in cardiovascular disease. But studies showed that long-term oral administration of GP IIb/IIIa receptor inhibitors has been ineffective in preventing ischemic events. Paradoxically, they have been linked to a high risk of side effects by producing prothrombotic and pro-inflammatory events.
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8
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Yamaguchi A, Stanger L, Freedman JC, Prieur A, Thav R, Tena J, Holman TR, Holinstat M. Supplementation with omega-3 or omega-6 fatty acids attenuates platelet reactivity in postmenopausal women. Clin Transl Sci 2022; 15:2378-2391. [PMID: 35791734 PMCID: PMC9579391 DOI: 10.1111/cts.13366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/18/2022] [Accepted: 06/26/2022] [Indexed: 01/25/2023] Open
Abstract
Postmenopausal women are at increased risk for a cardiovascular event due to platelet hyperactivity. There is evidence suggesting that ω-3 polyunsaturated fatty acids (PUFAs) and ω-6 PUFAs have cardioprotective effects in these women. However, a mechanistic understanding of how these fatty acids regulate platelet function is unknown. In this study, we supplemented postmenopausal women with fish oil (ω-3 fatty acids) or evening primrose oil (ω-6 fatty acids) and investigated the effects on their platelet activity. The effects of fatty acid supplementation on platelet aggregation, dense granule secretion, and activation of integrin αIIbβ3 at basal levels and in response to agonist were tested in postmenopausal women following a supplementation and washout period. Supplementation with fish oil or primrose oil attenuated the thrombin receptor PAR4-induced platelet aggregation. Supplementation with ω-3 or ω-6 fatty acids decreased platelet dense granule secretion and attenuated basal levels of integrin αIIbβ3 activation. Interestingly, after the washout period following supplementation with primrose oil, platelet aggregation was similarly attenuated. Additionally, for either treatment, the observed protective effects post-supplementation on platelet dense granule secretion and basal levels of integrin activation were sustained after the washout period, suggesting a long-term shift in platelet reactivity due to fatty acid supplementation. These findings begin to elucidate the underlying mechanistic effects of ω-3 and ω-6 fatty acids on platelet reactivity in postmenopausal women. Hence, this study supports the beneficial effects of fish oil or primrose oil supplementation as a therapeutic intervention to reduce the risk of thrombotic events in postmenopausal women. https://clinicaltrials.gov/ct2/show/NCT02629497.
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Affiliation(s)
- Adriana Yamaguchi
- Department of PharmacologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Livia Stanger
- Department of PharmacologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - John Cody Freedman
- Department of Chemistry and BiochemistryUniversity of California Santa CruzSanta CruzCaliforniaUSA
| | - Amanda Prieur
- Department of PharmacologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Rachel Thav
- Department of PharmacologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA,Cranbrook SchoolsBloomfield HillsMichiganUSA
| | - Jennyfer Tena
- Department of Chemistry and BiochemistryUniversity of California Santa CruzSanta CruzCaliforniaUSA
| | - Theodore R. Holman
- Department of Chemistry and BiochemistryUniversity of California Santa CruzSanta CruzCaliforniaUSA
| | - Michael Holinstat
- Department of PharmacologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA,Department of Internal Medicine, Division of Cardiovascular MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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9
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Capranzano P, Angiolillo DJ. Basics of Antiplatelet and Anticoagulant Therapy for Cardiovascular Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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10
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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11
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Simonato D, Borchert RJ, Labeyrie MA, Fuschi M, Thibault L, Henkes H, Fiorella D, Tan BYQ, Yeo LLL, Makalanda HLD, Wong K, Bhogal P. Glycoprotein IIb/IIIa inhibitors for the neurointerventionalist. Interv Neuroradiol 2022; 28:84-91. [PMID: 33947250 PMCID: PMC8905078 DOI: 10.1177/15910199211015038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/22/2021] [Accepted: 04/07/2021] [Indexed: 02/03/2023] Open
Abstract
Antiplatelet therapies are commonly used in neurointerventional procedures. However, specific guidelines for their use in these settings is lacking and it can often be difficult to balance the potential risks and benefits of these medications. Considering the continued growth and adoption of neurointerventional procedures, it is crucial to understand the properties of these agents in order to use them safely. Large-scale clinical trials are still needed to clarify many of these aspects for this emerging field. However, the existing literature already provides insight into which antiplatelet drugs are of benefit to the neurointerventionalist as well as their associated risks of ischemic and hemorrhagic complications. Hence, this review focuses on the applications of GPIIb/IIIA inhibitors to neurointerventional procedures.
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Affiliation(s)
- Davide Simonato
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, UK
- Institute of Radiology, University of Padova, Italy
| | - Robin J Borchert
- Department of Clinical Neurosciences, University of Cambridge, UK
| | | | - Maurizio Fuschi
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, UK
| | | | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University Hospital, New York, USA
| | - Benjamin YQ Tan
- Division of Neurology, National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Leonard LL Yeo
- Division of Neurology, National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ken Wong
- Royal London Hospital, London, UK
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Gribovskaya OV, Martinovich VP, Rodko EV, Rasyuk ED, Ryabtseva TV, Golubovich VP. Mimetics of the Arg-Gly-Asp Sequence: Synthesis and Studies of the Antiaggregative Properties. RUSSIAN JOURNAL OF BIOORGANIC CHEMISTRY 2021. [DOI: 10.1134/s106816202106008x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract—
It is known that the Arg-Gly-Asp sequence in the fibrinogen molecule is key in binding to the receptors on the surface of platelets. We searched for the compounds which were able to inhibit the binding and synthesized the following analogs of this sequence: 2-acetoxybenzoyl-Arg-βAla-Asp, 4-piperidinecarbonyl-βAla-Asp, and 4-aminobezoyl-βAla-Asp. These compounds were shown to inhibit the platelets aggregation in a different degree. The 2-acetoxybenzoyl-Arg-βAla-Asp analog demonstrated the highest inhibitory activity. A decrease in the expression of the CD62p and CD63 markers on platelets was also found after the action of the Arg-Gly-Asp analogs, confirming the ability of these compounds to block the fibrinogen binding sites for the GP IIb/IIIa glycoprotein receptors.
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13
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Gulati A, Tiwari A, Shetty V, Nwosu I, Khurana S. Tirofiban: A Rare Cause of Thrombocytopenia in a Patient Undergoing Percutaneous Coronary Intervention. Cureus 2021; 13:e18217. [PMID: 34722029 PMCID: PMC8544618 DOI: 10.7759/cureus.18217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
Patients admitted to the hospital can develop thrombocytopenia due to multifactorial causes. It can be pseudo-thrombocytopenia or true thrombocytopenia. Among patients admitted for chest pain, coronary angiography (CAG) is a common diagnostic test to evaluate patients for coronary artery disease (CAD). Normally, patients undergoing angiogram receive antiplatelets and anticoagulants pre-catheterization, and platelet aggregation inhibitor agents are sometimes used during and after CAG like in patients with high thrombus burden. Glycoprotein IIb/IIIa receptor inhibitors are a type of platelet antiaggregant agents that can cause severe thrombocytopenia in few cases. We present a case of a 68-year-old patient who came to the emergency department with inferior wall ST-segment elevation myocardial infarction and underwent angiography and had percutaneous coronary intervention (PCI) done. He was administered tirofiban during the angiogram that caused acute severe thrombocytopenia decreasing platelets count to 4000/microliter within one day. Patients' platelets gradually recovered after platelets transfusion.
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Affiliation(s)
- Amit Gulati
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Aparna Tiwari
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Vijay Shetty
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Ifeanyi Nwosu
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Sakshi Khurana
- Radiology, New York Presbyterian-Columbia University Irving Medical Center, New York City, USA
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14
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Yerasi C, Case BC, Chezar-Azerrad C, Forrestal BJ, Medranda GA, Shea C, Zhang C, Ben-Dor I, Satler LF, Bernardo NL, Hashim H, Garcia-Garcia HM, Waksman R. Cangrelor vs. glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention. Am Heart J 2021; 238:59-65. [PMID: 33961829 DOI: 10.1016/j.ahj.2021.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/24/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND To date, there are no real-world studies comparing cangrelor to glycoprotein IIb/IIIa inhibitors (GPI) during percutaneous coronary intervention (PCI). Thus, we performed this study to evaluate the safety and effectiveness of cangrelor compared to GPI during PCI. METHODS We identified patients who underwent PCI at our institution who received either cangrelor or GPI during PCI. Patients already on GPI or cangrelor prior to PCI or who received both cangrelor and GPI were excluded. Baseline demographics and clinical outcomes were extracted. Major bleeding is defined as a composite of major hematoma >4 cm, hematocrit drop >15, and gastrointestinal bleeding. RESULTS A total of 2072 patients received adjunctive antiplatelet therapy during PCI (cangrelor [n=478]; GPI [n=1594]). Patients' mean age was 61±12 years. Most (66%) presented with acute coronary syndrome. Patients who received cangrelor were older and had a higher percentage of acute coronary syndrome and lower baseline hematocrit in comparison with patients who received GPI. Procedural success was achieved in 94% of patients, with no difference between groups. Major bleeding events (1.7% vs. 5.1%, P=.001), any vascular complication rates, and hospital length of stay were significantly lower in the cangrelor group. In-hospital ischemic events did not differ between groups. On regression analysis, patients on cangrelor were noted to have significantly lower major bleeding events (OR 0.23; 95% CI, 0.09-0.59). CONCLUSIONS Balancing ischemic and bleeding risks with adjunctive antiplatelet drugs is of prime importance during PCI. Our real-world analysis shows that cangrelor is safe and effective when compared to GPI during PCI.
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Affiliation(s)
- Charan Yerasi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Chava Chezar-Azerrad
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Brian J Forrestal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Giorgio A Medranda
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Corey Shea
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Hayder Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Hector M Garcia-Garcia
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
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15
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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16
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Revilla-Martí P, Linares-Vicente JA, Martínez Labuena A, Jiménez Melo O, Morlanes Gracia P, Meseguer González D, Lukic A, Simó Sánchez B, Ruiz Arroyo JR. Efficacy and safety of abciximab versus tirofiban in addition to ticagrelor in STEMI patients undergoing primary percutaneous intervention. Platelets 2021; 33:265-272. [PMID: 33560898 DOI: 10.1080/09537104.2021.1881953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Platelet glycoprotein IIb/IIIa inhibitors (GPIs) have been part of the adjuvant treatment of acute coronary syndrome for years. However, real-life data regarding the efficacy and safety of GPIs under the current indications are lacking in the setting of potent platelet inhibition. The objectives were to assess the efficacy and safety of abciximab versus tirofiban in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) and pretreated with ticagrelor, and to identify independent predictor factors of efficacy, bleeding and platelet drop. Three hundred sixty-two patients were divided by GPI administered. Clinical, laboratory, angiographic and outcome characteristics were compared. The primary objective was a composite efficacy endpoint (death from any cause, nonfatal myocardial infarction and nonfatal stroke) at 30 days. The secondary objectives were its individual components, safety (bleeding) and the impact on platelet count during hospital stay. The composite efficacy endpoint was similar in the abciximab and tirofiban groups (6.1% vs 7.3%; p = .632). There were also no differences in cardiovascular death (2.5% vs 2.4%; p = .958), nonfatal myocardial infarction (3% vs 4.3%; p = .521) and nonfatal stroke (0.5% vs 1.8%; p = .332). Tirofiban administration was associated with a higher incidence of bleeding (11.6% vs 22%; p = .008) with no differences in BARC ≥ 3b bleeding (3.6 vs 2.5%; p = .760). In STEMI patients undergoing PPCI with ticagrelor, abciximab and tirofiban had similar rates in the composite efficacy endpoint at 30 days. The 30-day bleeding rate was significantly higher in the tirofiban group. Tirofiban administration was an independent predictor of both bleeding and platelet count drop.
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Affiliation(s)
- Pablo Revilla-Martí
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | | | - Ana Martínez Labuena
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Octavio Jiménez Melo
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Paula Morlanes Gracia
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | | | - Antonela Lukic
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Borja Simó Sánchez
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Jose R Ruiz Arroyo
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
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17
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Zhang J, Wang T, Saigal A, Johnson J, Morrisson J, Tabrizifard S, Hollingsworth SA, Eddins MJ, Mao W, O'Neill K, Garcia-Calvo M, Carballo-Jane E, Liu D, Ham T, Zhou Q, Dong W, Meng HW, Hicks J, Cai TQ, Akiyama T, Pinto S, Cheng AC, Greshock T, Marquis JC, Ren Z, Talukdar S, Shaheen HH, Handa M. Discovery of a new class of integrin antibodies for fibrosis. Sci Rep 2021; 11:2118. [PMID: 33483531 PMCID: PMC7822819 DOI: 10.1038/s41598-021-81253-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/05/2021] [Indexed: 12/14/2022] Open
Abstract
Lung fibrosis, or the scarring of the lung, is a devastating disease with huge unmet medical need. There are limited treatment options and its prognosis is worse than most types of cancer. We previously discovered that MK-0429 is an equipotent pan-inhibitor of αv integrins that reduces proteinuria and kidney fibrosis in a preclinical model. In the present study, we further demonstrated that MK-0429 significantly inhibits fibrosis progression in a bleomycin-induced lung injury model. In search of newer integrin inhibitors for fibrosis, we characterized monoclonal antibodies discovered using Adimab's yeast display platform. We identified several potent neutralizing integrin antibodies with unique human and mouse cross-reactivity. Among these, Ab-31 blocked the binding of multiple αv integrins to their ligands with IC50s comparable to those of MK-0429. Furthermore, both MK-0429 and Ab-31 suppressed integrin-mediated cell adhesion and latent TGFβ activation. In IPF patient lung fibroblasts, TGFβ treatment induced profound αSMA expression in phenotypic imaging assays and Ab-31 demonstrated potent in vitro activity at inhibiting αSMA expression, suggesting that the integrin antibody is able to modulate TGFβ action though mechanisms beyond the inhibition of latent TGFβ activation. Together, our results highlight the potential to develop newer integrin therapeutics for the treatment of fibrotic lung diseases.
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Affiliation(s)
- Ji Zhang
- Departments of Cardiometabolic Diseases, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA.
| | - Tao Wang
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Ashmita Saigal
- Departments of Cardiometabolic Diseases, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Josephine Johnson
- Quantitative Biosciences, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Jennifer Morrisson
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Sahba Tabrizifard
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Scott A Hollingsworth
- Computational & Structural Chemistry, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Michael J Eddins
- Computational & Structural Chemistry, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Wenxian Mao
- Quantitative Biosciences, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Kim O'Neill
- In Vitro Pharmacology, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Margarita Garcia-Calvo
- In Vitro Pharmacology, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Ester Carballo-Jane
- Quantitative Biosciences, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - DingGang Liu
- SALAR, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Taewon Ham
- SALAR, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Qiong Zhou
- SALAR, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Weifeng Dong
- SALAR, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Hsien-Wei Meng
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Jacqueline Hicks
- Discovery Chemistry, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Tian-Quan Cai
- In Vivo Pharmacology, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Taro Akiyama
- Departments of Cardiometabolic Diseases, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Shirly Pinto
- Departments of Cardiometabolic Diseases, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Alan C Cheng
- Computational & Structural Chemistry, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Thomas Greshock
- Discovery Chemistry, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - John C Marquis
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Zhao Ren
- Quantitative Biosciences, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Saswata Talukdar
- Departments of Cardiometabolic Diseases, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Hussam Hisham Shaheen
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Masahisa Handa
- Discovery Biologics, MRL, Merck & Co., Inc., 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA.
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18
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Beavers CJ, Jennings DL. Use of Glycoprotein IIb/IIIa Inhibitors in the Modern Era of Acute Coronary Syndrome Management: A Survey of Cardiovascular Clinical Pharmacists. J Pharm Pract 2019; 34:372-377. [PMID: 32423271 DOI: 10.1177/0897190019872386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Evidence for the use of glycoprotein IIb/IIIa inhibitors (GPIs) in the management of acute coronary syndrome (ACS) is from the era of either limited utilization of P2Y12 inhibitors or prior the introduction of more potent P2Y12 inhibitors. This leads to divergent opinions regarding the role of these agents in contemporary practice. This study sought the opinion of cardiovascular clinical pharmacists regarding the role of GPIs in the modern of ACS management. A 13-question survey was created and distributed from June 2018 to July 2018 via the American College of Clinical Pharmacy's Cardiology Practice and Research Network e-mail listserv. The survey consisted of questions regarding the ideal use of GPIs in ACS management, preferred agent selection, and rational for selection. All results were analyzed with descriptive statistics. There were a total 69 responses of 1175 (response rate 5.9%). The majority felt there was still a role for GPI in accordance to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for ST-segment elevation myocardial infarction (65.2%), with eptifibatide being preferred (55.1%). For non-ST-segment myocardial infraction (NSTEMI), only 49.3% felt role of GPI was in line with the ACC/AHA guidelines, but a notable number of respondents felt GPIs were only indicated in NSTEMI patients for bailout or thrombotic complications (18.8%). A majority (56.5%) felt GPIs could be used as an alternative for cangrelor when bridging. The decision to use one agent over another were efficacy data, cost, and pharmacokinetic profile.
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Affiliation(s)
- Craig J Beavers
- University of Kentucky Health Care, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Douglas L Jennings
- Heart Transplant, NewYork-Presbyterian 5798Columbia University Irving Medical Center, New York, NY, USA
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19
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Lazarovici P, Marcinkiewicz C, Lelkes PI. From Snake Venom's Disintegrins and C-Type Lectins to Anti-Platelet Drugs. Toxins (Basel) 2019; 11:toxins11050303. [PMID: 31137917 PMCID: PMC6563238 DOI: 10.3390/toxins11050303] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 12/13/2022] Open
Abstract
Snake venoms are attractive natural sources for drug discovery and development, with a number of substances either in clinical use or in research and development. These drugs were developed based on RGD-containing snake venom disintegrins, which efficiently antagonize fibrinogen activation of αIIbβ3 integrin (glycoprotein GP IIb/IIIa). Typical examples of anti-platelet drugs found in clinics are Integrilin (Eptifibatide), a heptapeptide derived from Barbourin, a protein found in the venom of the American Southeastern pygmy rattlesnake and Aggrastat (Tirofiban), a small molecule based on the structure of Echistatin, and a protein found in the venom of the saw-scaled viper. Using a similar drug discovery approach, linear and cyclic peptides containing the sequence K(R)TS derived from VP12, a C-type lectin protein found in the venom of Israeli viper venom, were used as a template to synthesize Vipegitide, a novel peptidomimetic antagonist of α2β1 integrin, with anti-platelet activity. This review focus on drug discovery of these anti-platelet agents, their indications for clinical use in acute coronary syndromes and percutaneous coronary intervention based on several clinical trials, as well as their adverse effects.
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Affiliation(s)
- Philip Lazarovici
- School of Pharmacy Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel.
| | - Cezary Marcinkiewicz
- Department of Bioengineering, College of Engineering, Temple University, Philadelphia, PA 19122, USA.
| | - Peter I Lelkes
- Department of Bioengineering, College of Engineering, Temple University, Philadelphia, PA 19122, USA.
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Yi YH, Yin WJ, Gu ZC, Fang WJ, Li DY, Hu C, Liu K, Ma RR, Zhou LY. A Simple Clinical Pre-procedure Risk Model for Predicting Thrombocytopenia Associated With Periprocedural Use of Tirofiban in Patients Undergoing Percutaneous Coronary Intervention. Front Pharmacol 2019; 9:1456. [PMID: 30618750 PMCID: PMC6295459 DOI: 10.3389/fphar.2018.01456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 11/28/2018] [Indexed: 11/13/2022] Open
Abstract
Background: No risk model for predicting thrombocytopenia associated with periprocedural tirofiban exposure is available. The purpose of this study was to develop a simple clinical pre-procedure risk model based on pre-procedural characteristics for early prediction of thrombocytopenia before patients were exposed to tirofiban. Methods: The series included 1862 patients who underwent percutaneous coronary intervention with tirofiban exposure. Baseline demographic and clinical characteristics were collected from the hospital information system on admission. The earliest pro-procedural platelets within 72 h were used to evaluate the thrombocytopenia incidence. Risk factors associated with thrombocytopenia in patients with tirofiban exposure were investigated by univariable and multivariable analyses. Locally weighted scatterplot smoothing procedure was used to identify the cut points for the numeric variables. The discriminatory power of the scoring system was assessed with the receiver operating characteristic (ROC) curve analysis. Results: The occurrence of thrombocytopenia was 4.02% (75 of 1862), 4.01% (56 of 1396), and 4.08% (19 of 466) in the overall, developmental, and validation data sets, respectively. The risk score was developed based on five independent predictors: age ≥65y, white blood cell ≥12 × 109/L, diabetes mellitus, congestive heart failure, and chronic kidney disease. This tool was well calibrated (Hosmer Lemeshow χ2 = 6.914; P = 0.546) and good discrimination was well obtained in validation data set (C-statistic, 0.82). Conclusion: The clinical pre-procedure risk model is a simple and accurate tool for early identification of high-risk patients of thrombocytopenia before tirofiban exposure, allowing for timely and appropriate intervention.
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Affiliation(s)
- Yi-Hu Yi
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China.,School of Xiangya Medical Science, Central South University, Changsha, China
| | - Wen-Jun Yin
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei-Jin Fang
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Dai-Yang Li
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China.,School of Xiangya Medical Science, Central South University, Changsha, China
| | - Can Hu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China.,School of Xiangya Medical Science, Central South University, Changsha, China
| | - Kun Liu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China.,School of Xiangya Medical Science, Central South University, Changsha, China
| | - Rong-Rong Ma
- College of Pharmacy, Xinjiang Medical University, Xinjiang, China
| | - Ling-Yun Zhou
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
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21
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Mahtta D, Bavry AA. αIIbβ3 (GPIIb-IIIa) Antagonists. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00052-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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22
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Yeung J, Li W, Holinstat M. Platelet Signaling and Disease: Targeted Therapy for Thrombosis and Other Related Diseases. Pharmacol Rev 2018; 70:526-548. [PMID: 29925522 PMCID: PMC6013590 DOI: 10.1124/pr.117.014530] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Platelets are essential for clotting in the blood and maintenance of normal hemostasis. Under pathologic conditions such as atherosclerosis, vascular injury often results in hyperactive platelet activation, resulting in occlusive thrombus formation, myocardial infarction, and stroke. Recent work in the field has elucidated a number of platelet functions unique from that of maintaining hemostasis, including regulation of tumor growth and metastasis, inflammation, infection, and immune response. Traditional therapeutic targets for inhibiting platelet activation have primarily been limited to cyclooxygenase-1, integrin αIIbβ3, and the P2Y12 receptor. Recently identified signaling pathways regulating platelet function have made it possible to develop novel approaches for pharmacological intervention in the blood to limit platelet reactivity. In this review, we cover the newly discovered roles for platelets as well as their role in hemostasis and thrombosis. These new roles for platelets lend importance to the development of new therapies targeted to the platelet. Additionally, we highlight the promising receptor and enzymatic targets that may further decrease platelet activation and help to address the myriad of pathologic conditions now known to involve platelets without significant effects on hemostasis.
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Affiliation(s)
- Jennifer Yeung
- Departments of Pharmacology (J.Y., W.L., M.H.) and Internal Medicine, Division of Cardiovascular Medicine (M.H.), University of Michigan, Ann Arbor, Michigan
| | - Wenjie Li
- Departments of Pharmacology (J.Y., W.L., M.H.) and Internal Medicine, Division of Cardiovascular Medicine (M.H.), University of Michigan, Ann Arbor, Michigan
| | - Michael Holinstat
- Departments of Pharmacology (J.Y., W.L., M.H.) and Internal Medicine, Division of Cardiovascular Medicine (M.H.), University of Michigan, Ann Arbor, Michigan
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23
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Dal-Ré R, Janiaud P, Ioannidis JPA. Real-world evidence: How pragmatic are randomized controlled trials labeled as pragmatic? BMC Med 2018; 16:49. [PMID: 29615035 PMCID: PMC5883397 DOI: 10.1186/s12916-018-1038-2] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/15/2018] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Pragmatic randomized controlled trials (RCTs) mimic usual clinical practice and they are critical to inform decision-making by patients, clinicians and policy-makers in real-world settings. Pragmatic RCTs assess effectiveness of available medicines, while explanatory RCTs assess efficacy of investigational medicines. Explanatory and pragmatic are the extremes of a continuum. This debate article seeks to evaluate and provide recommendation on how to characterize pragmatic RCTs in light of the current landscape of RCTs. It is supported by findings from a PubMed search conducted in August 2017, which retrieved 615 RCTs self-labeled in their titles as "pragmatic" or "naturalistic". We focused on 89 of these trials that assessed medicines (drugs or biologics). DISCUSSION 36% of these 89 trials were placebo-controlled, performed before licensing of the medicine, or done in a single-center. In our opinion, such RCTs overtly deviate from usual care and pragmatism. It follows, that the use of the term 'pragmatic' to describe them, conveys a misleading message to patients and clinicians. Furthermore, many other trials among the 615 coined as 'pragmatic' and assessing other types of intervention are plausibly not very pragmatic; however, this is impossible for a reader to tell without access to the full protocol and insider knowledge of the trial conduct. The degree of pragmatism should be evaluated by the trial investigators themselves using the PRECIS-2 tool, a tool that comprises 9 domains, each scored from 1 (very explanatory) to 5 (very pragmatic). CONCLUSIONS To allow for a more appropriate characterization of the degree of pragmatism in clinical research, submissions of RCTs to funders, research ethics committees and to peer-reviewed journals should include a PRECIS-2 tool assessment done by the trial investigators. Clarity and accuracy on the extent to which a RCT is pragmatic will help understand how much it is relevant to real-world practice.
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Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, E-28040, Madrid, Spain
| | - Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, 94305, USA
| | - John P A Ioannidis
- Departments of Medicine, Health Research and Policy, Biomedical Data Science, Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, 94305, USA.
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24
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Force-activatable biosensor enables single platelet force mapping directly by fluorescence imaging. Biosens Bioelectron 2017; 100:192-200. [PMID: 28915383 DOI: 10.1016/j.bios.2017.09.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/25/2017] [Accepted: 09/05/2017] [Indexed: 11/23/2022]
Abstract
Integrin-transmitted cellular forces are critical for platelet adhesion, activation, aggregation and contraction during hemostasis and thrombosis. Measuring and mapping single platelet forces are desired in both research and clinical applications. Conventional force-to-strain based cell traction force microscopies have low resolution which is not ideal for cellular force mapping in small platelets. To enable platelet force mapping with submicron resolution, we developed a force-activatable biosensor named integrative tension sensor (ITS) which directly converts molecular tensions to fluorescent signals, therefore enabling cellular force mapping directly by fluorescence imaging. With ITS, we mapped cellular forces in single platelets at 0.4µm resolution. We found that platelet force distribution has strong polarization which is sensitive to treatment with the anti-platelet drug tirofiban, suggesting that the ITS force map can report anti-platelet drug efficacy. The ITS also calibrated integrin molecular tensions in platelets and revealed two distinct tension levels: 12-54 piconewton (nominal values) tensions generated during platelet adhesion and tensions above 54 piconewton generated during platelet contraction. Overall, the ITS is a powerful biosensor for the study of platelet mechanobiology, and holds great potential in antithrombotic drug development and assessing platelet activity in health and disease.
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25
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Sukul D, Seth M, Schreiber T, Hanzel G, Khandelwal A, Cannon LA, Lalonde TA, Gurm HS. The comparative safety of abciximab versus eptifibatide in patients on dialysis undergoing percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). J Interv Cardiol 2017; 30:291-300. [PMID: 28543770 PMCID: PMC6850214 DOI: 10.1111/joic.12388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES We sought to evaluate the patterns of use and outcomes associated with eptifibatide and abciximab administration among dialysis patients who underwent percutaneous coronary intervention (PCI). BACKGROUND Contraindicated medications are frequently administered to dialysis patients undergoing PCI often resulting in adverse outcomes. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that is often used during PCI and is contraindicated in dialysis. METHODS We included dialysis patients who underwent PCI from January 2010 to September 2015 at 47 hospitals in Michigan. We compared outcomes between patients who received eptifibatide compared with abciximab. Both groups required concurrent treatment with unfractionated heparin only. In-hospital outcomes included repeat PCI, bleeding, major bleeding, need for transfusion, and death. Optimal full matching was used to adjust for non-random drug administration. RESULTS Of 177 963 patients who underwent PCI, 4303 (2.4%) were on dialysis. Among those, 384 (8.9%) received eptifibatide and 100 (2.3%) received abciximab. Prior to matching, patients who received eptifibatide had higher pre-procedural hemoglobin levels (11.3 g/dL vs. 10.7 g/dL; P < 0.001) and less frequently had a history of myocardial infarction (36.5% vs. 52.0%; P = 0.005). After matching, there were no significant differences in in-hospital outcomes between eptifibatide and abciximab including transfusion (aOR: 1.15; 95%CI: 0.55-2.40; P = 0.70), bleeding (1.47; 0.64-3.40; P = 0.36), major bleeding (4.68; 0.42-52.3; P = 0.21), repeat PCI (0.38; 0.03-4.23; P = 0.43), and death (1.53; 0.2-9.05; P = 0.64). CONCLUSIONS Despite being contraindicated in dialysis, eptifibatide was used approximately 3.5 times more frequently than abciximab among dialysis patients undergoing PCI but was associated with similar in-hospital outcomes.
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Affiliation(s)
- Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - George Hanzel
- Division of Cardiology, Department of Medicine, William Beaumont Hospital, Heart and Vascular, Royal Oak, Michigan
| | | | - Louis A. Cannon
- McLaren-Northern Michigan Regional Hospital, Petoskey, Michigan
| | - Thomas A. Lalonde
- Department of Cardiovascular Medicine, St. John Hospital and Medical Center, Detroit, Michigan
| | - Hitinder S. Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
- Cardiovascular Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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26
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Martínez-Pérez R, Lownie SP, Pelz D. Intra-Arterial Use of Abciximab in Thromboembolic Complications Associated with Cerebral Aneurysm Coiling: The London Ontario Experience. World Neurosurg 2017; 100:342-350. [PMID: 28104522 DOI: 10.1016/j.wneu.2017.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/05/2017] [Accepted: 01/06/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Experience with intra-arterial infusion of abciximab for the treatment of endovascular thrombotic complications is limited to short case series. Our objective is to evaluate the safety and effectiveness of this drug for the treatment of thromboembolic complications during aneurysm coiling and to determine the risk factors. METHODS From an aneurysm coiling database, patients treated with intra-arterial abciximab after having thrombotic complications during the coiling procedure were selected for analysis. Complications after using abciximab were categorized as hemorrhage, distal migration of the thrombus, and aneurysm recanalization. RESULTS Fourteen coiling patients sustained a thromboembolic complication and were treated using intra-arterial infusion of abciximab and were subjected to further analysis. The age range was 48-76 years. Three patients were male. Seven patients had subarachnoid hemorrhage. Only complete recanalization was associated with clinical improvement, but this occurred in only 4 patients (28.5%). Partial or complete recanalization occurred in 13 patients (93%). Eight patients (57%) had complications derived from the infusion. Three patients had aneurysm recanalization, 3 patients had distal migration of the thrombus and 1 patient had a hemorrhagic complication. Eight patients demonstrated acute infarcts related to the occluded vessel, whereas 7 patients made a good functional recovery. CONCLUSION Successful recanalization of a vessel occluded by thrombus formation during aneurysm coiling using abciximab (Reopro) infusion is less than optimal. There are risks related to abciximab, including bleeding and aneurysm recanalization.
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Affiliation(s)
- Rafael Martínez-Pérez
- Departments of Clinical Neurological Sciences and Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Stephen P Lownie
- Departments of Clinical Neurological Sciences and Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - David Pelz
- Departments of Clinical Neurological Sciences and Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Abstract
Antiplatelet agents have for decades been used to improve outcomes in patients with acute coronary syndromes and have become increasingly valued, not only for their antithrombotic properties but also for their anti-inflammatory effects. The drug class continues to evolve as novel agents with increasingly efficacious antiplatelet actions are identified. This review will discuss antiplatelet agents, including aspirin, the P2Y12 receptor antagonists and the glycoprotein IIb/IIIa inhibitors, that are currently used to treat patients with unstable angina and myocardial infarction, focusing on their pharmacological properties and the clinical evidence supporting their use.
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Affiliation(s)
- Kerry Layne
- Department of Clinical Pharmacology, Cardiovascular Division, King's College London, London, UK
| | - Albert Ferro
- Department of Clinical Pharmacology, Cardiovascular Division, King's College London, London, UK
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28
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Yost GW, Steinhubl SR. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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29
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Ghobrial J, Burke DA, Pinto DS. Role of Parenteral Agents in PCI for Stable Patients. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joanna Ghobrial
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - David A. Burke
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Duane S. Pinto
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
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30
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Capranzano P, Angiolillo DJ. Basics of Antiplatelet and Anticoagulant Therapy for Cardiovascular Disease. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Piera Capranzano
- Cardiovascular Department, Ferrarotto Hospital; University of Catania; Catania Italy
| | - Dominick J. Angiolillo
- Department of Medicine, Division of Cardiology; University of Florida College of Medicine-Jacksonville; Jacksonville FL USA
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31
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Affiliation(s)
- Stuart J Pocock
- From the Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London (S.J.P.); and Columbia University Medical Center, New York Presbyterian Hospital, and the Cardiovascular Research Foundation - all in New York (G.W.S.)
| | - Gregg W Stone
- From the Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London (S.J.P.); and Columbia University Medical Center, New York Presbyterian Hospital, and the Cardiovascular Research Foundation - all in New York (G.W.S.)
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Mottillo S, Filion KB, Joseph L, Eisenberg MJ. Defining optimal activated clotting time for percutaneous coronary intervention: A systematic review and Bayesian meta-regression. Catheter Cardiovasc Interv 2016; 89:351-366. [DOI: 10.1002/ccd.26652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 05/09/2016] [Accepted: 06/04/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Salvatore Mottillo
- Center for Clinical Epidemiology; Lady Davis Institute, Jewish General Hospital/McGill University; Montreal Quebec Canada
- Department of Epidemiology, Biostatistics, and Occupational Health; McGill University; Montreal Quebec Canada
- Department of Emergency Medicine; McGill University Health Center; Montreal Quebec Canada
| | - Kristian B. Filion
- Center for Clinical Epidemiology; Lady Davis Institute, Jewish General Hospital/McGill University; Montreal Quebec Canada
- Department of Epidemiology, Biostatistics, and Occupational Health; McGill University; Montreal Quebec Canada
- Division of Clinical Epidemiology; Department of Medicine; McGill University; Montreal Quebec Canada
| | - Lawrence Joseph
- Department of Epidemiology, Biostatistics, and Occupational Health; McGill University; Montreal Quebec Canada
- Division of Clinical Epidemiology; McGill University Health Center; Montreal Quebec Canada
| | - Mark J. Eisenberg
- Center for Clinical Epidemiology; Lady Davis Institute, Jewish General Hospital/McGill University; Montreal Quebec Canada
- Department of Epidemiology, Biostatistics, and Occupational Health; McGill University; Montreal Quebec Canada
- Divisions of Cardiology and Clinical Epidemiology; Jewish General Hospital/McGill University; Montreal Quebec Canada
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Puddu PE, Iannetta L, Placanica A, Cuturello D, Schiariti M, Manfrini O. The role of Glycoprotein IIb/IIIa inhibitors in acute coronary syndromes and the interference with anemia. Int J Cardiol 2016; 222:1091-1096. [PMID: 27522492 DOI: 10.1016/j.ijcard.2016.07.207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/28/2016] [Indexed: 11/27/2022]
Abstract
The role played by glycoprotein (GP) IIb/IIIa inhibitors (GPI) has continuously evolved until the most recent Guidelines whereby they were stepped down from class I to class II recommendation for treating acute coronary syndromes (ACS). GPI compete with a wider use of ADP inhibitors and novel anticoagulant drugs although GPI use has greatly narrowed. However, GPI may still have a role. Several criteria were proposed to define post-PCI anemia which is strictly related to bleeding and transfusion. In ACS, it should be important to define anemia in comparative terms versus baseline levels: ≥ 15% of red blood cell decrease should be a practical cut-off value. If one wishes to concentrate on hemoglobin (Hb), a≥2g/dl Hb decrease from baseline should be considered. It is important to recognize post-PCI anemia in the setting of ACS. There are sub-populations exposed to short-term hemorrhagic and/or long-term ischemic risks. Ischemic and hemorrhagic risks need to be carefully evaluated along with thrombocytopenia and its prognostic significance in order to put all these blood and rheological parameters into a clinically oriented perspective on which therapeutical decisions should be based. Definition of high risk procedures (complexity, angiographic characteristics and patient's risk profile, regardless whether STEMI or NSTEMI) may help selecting GPI. There are positive elements in GPI use: efficacy, rapid onset and reversibility of action, absence of pharmacogenomic variability, pharmacoeconomic considerations and the possibility of intracoronary administration. All these elements should be evaluated when selecting these agents for therapeutics.
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Affiliation(s)
- Paolo Emilio Puddu
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Loredana Iannetta
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Attilio Placanica
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Domenico Cuturello
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Michele Schiariti
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Italy.
| | - Olivia Manfrini
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater University, Bologna, Italy.
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Raphael CE, Spoon DB, Bell MR, Psaltis PJ, Kidd S, Loh SX, Lennon RJ, Singh M, Rihal C, Gulati R. Effect of Preprocedural Thrombocytopenia on Prognosis After Percutaneous Coronary Intervention. Mayo Clin Proc 2016; 91:1035-44. [PMID: 27492910 DOI: 10.1016/j.mayocp.2016.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/18/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess early and late outcomes, including bleeding, in patients with thrombocytopenia undergoing percutaneous coronary intervention (PCI). PATIENTS AND METHODS We performed a retrospective single-center study of patients with preprocedural thrombocytopenia (platelet count ≤100,000/μL; n=204) undergoing PCI between 2003 and 2015. Inhospital and late outcomes were compared with those of a matched control group without thrombocytopenia (n=1281). RESULTS The most common causes of thrombocytopenia were liver disease, immune-mediated disease, and hematologic malignant neoplasms. Inhospital bleeding events after PCI were similar in patients with thrombocytopenia and matched controls (24 of 146 [16.4%] vs 179 of 1281 [14.0%]; P=.40) and were largely classified as minor using the Bleeding Academic Research Consortium (BARC) classification (89% BARC 1 or 2). There was no significant difference in inhospital death (4 of 146 [2.7%] vs 71 of 1281 [2.0%]; P=.56), but patients with thrombocytopenia had higher rates of platelet and red blood cell transfusion (18 of 146 [12.3%] vs 93 of 1281 [7.2%]; P=.05). During long-term follow-up, Kaplan-Meier estimated rates of bleeding events (BARC ≥2) were higher for thrombocytopenia (at 5 years, 7.9% vs 3.6%; P=.03). Patients with thrombocytopenia had a similar risk of long-term cardiac mortality, but significantly higher rates of noncardiac mortality (at 5 years, 28% vs 21%; P=.02). CONCLUSION This study suggests that short-term outcomes after PCI in patients with thrombocytopenia were favorable. On long-term follow-up, thrombocytopenia was associated with a higher risk of long-term noncardiac mortality and bleeding.
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Affiliation(s)
| | - Daniel B Spoon
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Shu X Loh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Mandeep Singh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Charanjit Rihal
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Rajiv Gulati
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Ali ZA, Qureshi YH, Karimi Galougahi K, Poludasu S, Roye S, Krishnan P, Zalewski A, Shah ZZ, Bhatti N, Kalapatapu K, Mehran R, Dangas G, Kini AS, Sharma SK. Effects of baseline and early acquired thrombocytopaenia on long-term mortality in patients undergoing percutaneous coronary intervention with bivalirudin. EUROINTERVENTION 2016; 11:e1627-38. [DOI: 10.4244/eijv11i14a314] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Glycoprotein IIb/IIIa inhibitors: The resurgence of tirofiban. Vascul Pharmacol 2016; 78:10-6. [DOI: 10.1016/j.vph.2015.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/12/2015] [Accepted: 07/13/2015] [Indexed: 11/18/2022]
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Mansur ADP, Roggerio A, Takada JY, Caribé PMV, Avakian SD, Strunz CMC. Gene mutations of platelet glycoproteins and response to tirofiban in acute coronary syndrome. SAO PAULO MED J 2016; 134:199-204. [PMID: 26786608 PMCID: PMC10496600 DOI: 10.1590/1516-3180.2015.00650808] [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: 08/05/2015] [Revised: 03/26/2015] [Accepted: 08/08/2015] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVES Glycoprotein inhibitors (abciximab, eptifibatide and tirofiban) are used in patients with unstable angina and non-ST-segment elevation myocardial infarction before percutaneous coronary intervention. Of these, tirofiban is the least effective. We hypothesized that the response to tirofiban might be associated with glycoprotein gene mutations. DESIGN AND SETTING Prospective study at Emergency Unit, Heart Institute (InCor), University of São Paulo. METHOD Intrahospital evolution and platelet aggregation in response to tirofiban were analyzed in relation to four glycoprotein mutations in 50 patients indicated for percutaneous coronary intervention: 17 (34%) with unstable angina and 33 (66%) with non-ST-segment elevation myocardial infarction. Platelet aggregation was analyzed using the Born method. Blood samples were obtained before and one hour after tirofiban infusion. Glycoproteins Ia (807C/T ), Ib (Thr/Met) , IIb (Ile/Ser ) and IIIa (PIA ) were the mutations selected. RESULTS Hypertension, dyslipidemia, diabetes, smoking, previous coronary artery disease and stroke were similar between the groups. Mutant glycoprotein IIIa genotypes had lower platelet aggregation before tirofiban administration than that of the wild genotype (41.0% ± 22.1% versus 55.9% ± 20.8%; P = 0.035). Mutant glycoprotein IIIa genotypes correlated moderately with lower platelet inhibition (r = -0.31; P = 0.030). After tirofiban administration, platelet glycoprotein Ia, Ib, IIb and IIIa mutations did not influence the degree of inhibition of platelet aggregation or intrahospital mortality. CONCLUSIONS Mutations of glycoproteins Ia, Ib, IIb and IIIa did not influence platelet aggregation in response to tirofiban in patients with unstable angina and non-ST-segment elevation myocardial infarction.
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Affiliation(s)
- Antonio de Padua Mansur
- MD, PhD. Associate Professor, Department of Cardiopulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Alessandra Roggerio
- BSc, PhD. Biochemist, Department of Cardiopulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Júlio Yoshio Takada
- MD, PhD. Attending Physician, Department of Cardiopulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Pérola Michelle Vasconcelos Caribé
- MD, MSc. Doctoral Student, Department of Cardiopulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Solange Desirée Avakian
- MD, PhD. Attending Physician, Department of Cardiopulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Célia Maria Cassaro Strunz
- BSc. Central Laboratory Director, Department of Cardiopulmonology, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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The Impact of Thrombocytopenia on Outcome in Patients with Acute Coronary Syndromes: A Single Center Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:907304. [PMID: 26504845 PMCID: PMC4609406 DOI: 10.1155/2015/907304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/14/2015] [Indexed: 12/02/2022]
Abstract
Background. In acute coronary syndromes (ACS), treated by combined antithrombotic therapy and percutaneous coronary interventions (PCI), thrombocytopenia may occur. Our aim was to evaluate predictors and the impact of thrombocytopenia on mortality in high-risk ACS patients. Methods. We retrospectively evaluated high-risk ACS patients. Thrombocytopenia was defined as platelet count <140.000/mL or a drop in platelet count of >50% during in-hospital stay. We compared demographic, laboratory, clinical, and mortality data between nonthrombocytopenic and thrombocytopenic ACS patients and evaluated independent predictors of thrombocytopenia. Results. In 371 ACS patients, thrombocytopenia was observed in 21.3%. Thrombocytopenic patients were significantly older and, less likely treated by PCIs (72.1% versus 89.7%, p < 0.001) and combined antithrombotic therapy, with increased incidence of in-hospital complications and the use of additional treatments, but with increased mortality at 30 days (27.8% versus 10.2%, p < 0.001) and 6 months (35.4% versus 13.6%, p < 0.001) when compared to nonthrombocytopenic patients. The use of antibiotics, transfusions, insertion of intra-aortic balloon pump (IABP), and prior stroke independently predicted thrombocytopenia. Conclusions. Thrombocytopenia, observed in about 20% of high-risk ACS patients, was associated significantly with in-hospital complications and mortality. Predictors of thrombocytopenia were the use of antibiotics, transfusions, insertion of IABP, and prior stroke.
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Kaymaz C, Keleş N, Özdemir N, Tanboğa İH, Demircan HC, Can MM, Koca F, İzgi İA, Özkan A, Türkmen M, Kırma C, Esen AM. The effects of tirofiban infusion on clinical and angiographic outcomes of patients with STEMI undergoing primary PCI. Anatol J Cardiol 2015; 15:899-906. [PMID: 25868037 PMCID: PMC5336940 DOI: 10.5152/akd.2014.5656] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: The present study was designed to determine the effects of tirofiban (Tiro) infusion on angiographic measures, ST-segment resolution, and clinical outcomes in patients with STEMI undergoing PCI. Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI), while the most effective timing of administration is still under investigation. Methods: A total of 1242 patients (83.0% males, mean (standard deviation; SD) age: 54.7 (10.9) years) with STEMI who underwent primary PCI were included in this retrospective non-randomized study in four groups, composed of no tirofiban infusion [Tiro (-); n=248], tirofiban infusion before PCI (pre-Tiro; n=720), tirofiban infusion during PCI (peri-Tiro; n=50), and tirofiban infusion after PCI (post-Tiro; n=224). In all Tiro (+) patients, bolus administration of Tiro (10 pg/kg) was followed by infusion (0.15 pg/kg/min) for a mean (SD) duration of 22.4±6.8 hours. Results: The pre-PCI Tiro group was associated with the highest percentage of patients with TIMI 3 flow (99.4%; p<0.001), the lowest corrected TIMI frame count [21(18-23.4); p<0.001], the highest percentage of patients with >75% ST-segment resolution (78.1%; p<0.001), and the lowest rate of in-hospital sudden cardiac death and in-hospital all-cause mortality (3.2%, p<0.05, 3.3%, p=0.01). Major bleeding was reported in 18 (1.8%) patients who received tirofiban. Conclusion: Use of standard-dose bolus tirofiban in addition to aspirin, high-dose clopidogrel, and unfractionated heparin prior to primary PCI significantly improves myocardial reperfusion, ST-segment resolution, in-hospital mortality rate, and in-hospital sudden cardiac death in patients with STEMI with no increased risk of major bleeding.
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Affiliation(s)
- Cihangir Kaymaz
- Department of Cardiology, Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital; İstanbul-Turkey.
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Goto S, Hasebe T, Takagi S. Platelets: Small in Size But Essential in the Regulation of Vascular Homeostasis – Translation From Basic Science to Clinical Medicine –. Circ J 2015; 79:1871-81. [DOI: 10.1253/circj.cj-14-1434] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine
- Department of Metabolic Disease Research Center, Tokai University Graduate School of Medicine
| | - Terumitsu Hasebe
- Department of Radiology, Tokai University Hachioji Hospital, Tokai University School of Medicine
| | - Shu Takagi
- Graduate School of Engineering, The University of Tokyo
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Galal H, Essmat E. Impact of upstream high bolus dose tirofiban on left ventricular systolic function in patients with acute anterior myocardial infarction treated by primary coronary intervention. Egypt Heart J 2014. [DOI: 10.1016/j.ehj.2014.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Vora AN, Chenier M, Schulte PJ, Goodman S, Peterson ED, Pieper K, Jolicoeur ME, Mahaffey KW, White H, Wang TY. Long-term outcomes associated with hospital acquired thrombocytopenia among patients with non-ST-segment elevation acute coronary syndrome. Am Heart J 2014; 168:189-96.e1. [PMID: 25066558 DOI: 10.1016/j.ahj.2014.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 04/09/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acquired thrombocytopenia after a non-ST-segment-elevation-acute coronary syndrome (NSTE-ACS) has been associated with increased in-hospital mortality and hemorrhagic complications, but longer term outcomes are unclear. We examined the association between thrombocytopenia and long-term outcomes after accounting for thrombocytopenia severity and discharge medication use. METHODS Data from 7,435 NSTE-ACS patients enrolled in the SYNERGY trial were analyzed. Severe thrombocytopenia was defined as a nadir platelet count <100 × 10(9)/L or a ≥ 50% drop from baseline. Mild thrombocytopenia was defined as a nadir platelet count between 100 and 149 × 10(9)/L with a <50% drop from baseline. The primary outcomes of interest were in-hospital GUSTO moderate-severe bleeding and 1-year mortality. RESULTS Overall, 675 patients (9.1%) developed mild thrombocytopenia and 139 patients (1.9%) developed severe thrombocytopenia. In-hospital bleeding risks were higher in patients with mild (7.7%, adjusted HR 1.63, 95% CI 1.16-2.29) or severe (28.2%, adjusted HR 6.93, 95% CI 4.55-10.56) thrombocytopenia than in patients without thrombocytopenia (5.2%). One-year mortality rates were 6.5%, 8.1%, and 28.1% among patients with no, mild, and severe thrombocytopenia, respectively (log rank P < 0.001) but only severe thrombocytopenia remained significantly associated with increased mortality after adjustment: HR 4.07, 95% CI 2.86-5.78. Patients who developed severe thrombocytopenia were less likely to be discharged on guideline-recommended antiplatelet therapy. The relationship between severe thrombocytopenia and mortality was attenuated by but persisted after adjusting for discharge medication use (HR 2.83, 95% CI 1.49-5.38). CONCLUSIONS Thrombocytopenia occurs commonly during the course of NSTE-ACS care; even mild decreases are associated with clinically meaningful bleeding. Patients who developed severe thrombocytopenia were less likely to be discharged on guideline-recommended antiplatelet therapy; this may contribute to their higher associated long-term mortality.
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Affiliation(s)
- Amit N Vora
- Duke Clinical Research Institute, Durham, NC.
| | | | | | - Shaun Goodman
- Division of Cardiology, St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre, Toronto, Canada
| | | | | | | | | | - Harvey White
- Green Lane Cardiovascular Service, Auckland, New Zealand
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A comprehensive acute coronary syndrome algorithm for centers with percutaneous coronary intervention capability. Crit Pathw Cardiol 2014; 12:141-9. [PMID: 23892945 DOI: 10.1097/hpc.0b013e318292f168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A comprehensive acute coronary syndrome (ACS) protocol was developed to improve the quality of care for patients admitted with definite or probable ACS. These protocols were constructed to streamline the practice for diverse clinicians who care for ACS patients across a variety of clinical settings. They are applicable in the emergency department, the cardiac catheterization laboratory, and the inpatient settings for hospitals with primary percutaneous coronary intervention capability. These protocols standardized the care by selecting the best therapy for each clinical scenario based on available established guidelines to insure the safest and highest value (quality/cost) medical care.
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The synthesis of 4,7-disubstituted-2H-benzo[b][1,4]-oxazin-3(4H)-ones using Smiles rearrangement and their in vitro evaluation as platelet aggregation inhibitors. Bioorg Med Chem Lett 2014; 24:1479-83. [PMID: 24565904 DOI: 10.1016/j.bmcl.2014.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/31/2014] [Accepted: 02/04/2014] [Indexed: 11/21/2022]
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Rationale for Upstream Dual Antiplatelet Therapy in Non-ST-Segment Elevation Myocardial Infarction. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014. [DOI: 10.1007/s40138-013-0037-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Mathewkutty S, McGuire DK. Platelet perturbations in diabetes: implications for cardiovascular disease risk and treatment. Expert Rev Cardiovasc Ther 2014; 7:541-9. [DOI: 10.1586/erc.09.30] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Acute coronary syndromes represent a major health problem in terms of incidence and mortality. Intracoronary platelet-rich thrombi may develop in response to plaque rupture, and are involved in the pathogenesis of all acute coronary syndromes. The glycoprotein IIb/IIIa receptor, a platelet surface integrin, plays a key role in platelet aggregation once it has been activated by specific ligands. The development of glycoprotein IIb/IIIa inhibitors has revolutionized the management of acute coronary syndromes. Tirofiban is one of three parenteral glycoprotein IIb/IIIa inhibitors in clinical use, and many trials have demonstrated its clinical efficacy and low rate of adverse effects in patients with non-ST-segment elevation acute coronary syndrome. This article reviews the data concerning its use in the clinical settings of acute coronary syndromes and percutaneous coronary angioplasty, and discusses its benefits in different treatment strategies and in association with other drugs. In particular, the role of early, upstream tirofiban coupled with early aggressive revascularization in the management of high-risk non-ST-segment elevation acute coronary syndromes is emphasized.
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Affiliation(s)
- Alberto Menozzi
- Division of Cardiology, Maggiore Hospital, University of Parma, Parma, Italy.
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Schneider DJ, Aggarwal A. Development of glycoprotein IIb–IIIa antagonists: translation of pharmacodynamic effects into clinical benefit. Expert Rev Cardiovasc Ther 2014; 2:903-13. [PMID: 15500435 DOI: 10.1586/14779072.2.6.903] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This article will review the development of glycoprotein IIb-IIIa antagonists, with particular emphasis on the characteristics and pharmacodynamic studies of each agent that is available for clinical use. Abciximab is a Fab fragment of the 7E3 antibody that has high affinity and a slow rate of dissociation from glycoprotein IIb-IIIa. In contrast, the small molecules eptifibatide and tirofiban, have a much more rapid rate of dissociation, with an off time of 10 to 15 s. Accordingly, the circulating pool of abciximab is predominantly associated with platelets, whereas maintenance of a consistent concentration of tirofiban and eptifibatide in the blood is critical in order to achieve and sustain their inhibitory effects. The affinity of abciximab and tirofiban for glycoprotein IIb-IIIa are substantially greater than that of eptifibatide, necessitating maintenance of greater molar concentrations of eptifibatide in blood in order to achieve effective inhibition of the binding of fibrinogen to the activated conformer of glycoprotein IIb-IIIa.
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Affiliation(s)
- David J Schneider
- University of Vermont, 208 South Park Drive, Suite 2, Colchester, VT 05446, USA.
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Zhu J, Zhang T, Xie Q, Zhang J. Effects of Upstream Administration of Tirofiban Before Percutaneous Coronary Intervention on Spontaneous Reperfusion and Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction. Angiology 2013; 66:70-8. [PMID: 24327765 DOI: 10.1177/0003319713514290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We assessed the effects of upstream administration of the glycoprotein IIb/IIIa inhibitor tirofiban before percutaneous coronary intervention (PCI) on spontaneous reperfusion (SR) of infarct-related artery (IRA) and the clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The incidence of SR of the IRA was significantly higher in the tirofiban group than in the no-tirofiban group (141 [36.5%] vs 21 [17.2%], P < .001). By multivariate logistic regression analysis, use of tirofiban (odds ratio 2.32, 95% confidence interval 1.25-4.31, P = .008) independently predicted the occurrence of SR. Kaplan-Meier survival analysis demonstrated that major adverse cardiovascular event-free survival was significantly higher in patients treated with tirofiban than in patients without tirofiban at 30-day (log rank = 11.65, P = .001) and 90-day follow-up (log rank = 16.79, P < .001). Upstream administration of tirofiban is significantly associated with increased SR of the IRA and favorable clinical prognosis in patients undergoing PCI for STEMI.
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Affiliation(s)
- Jianbing Zhu
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Tiantian Zhang
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qianqian Xie
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Junfeng Zhang
- Department of Cardiology, Third People’s Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Bosch X, Marrugat J, Sanchis J. Platelet glycoprotein IIb/IIIa blockers during percutaneous coronary intervention and as the initial medical treatment of non-ST segment elevation acute coronary syndromes. Cochrane Database Syst Rev 2013:CD002130. [PMID: 24203004 DOI: 10.1002/14651858.cd002130.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND During percutaneous coronary intervention (PCI), and in non-ST segment elevation acute coronary syndromes (NSTEACS), the risk of acute vessel occlusion by thrombosis is high. Glycoprotein IIb/IIIa blockers strongly inhibit platelet aggregation and may prevent mortality and myocardial infarction. This is an update of a Cochrane review first published in 2001, and previously updated in 2007 and 2010. OBJECTIVES To assess the efficacy and safety effects of glycoprotein IIb/IIIa blockers when administered during PCI, and as initial medical treatment in patients with NSTEACS. SEARCH METHODS We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 12, 2012), MEDLINE (OVID, 1946 to January Week 1 2013) and EMBASE (OVID, 1947 to Week 1 2013) on 11 January 2013. SELECTION CRITERIA Randomised controlled trials comparing intravenous IIb/IIIa blockers with placebo or usual care. DATA COLLECTION AND ANALYSIS Two authors independently selected studies for inclusion, assessed trial quality and extracted data. We collected major bleeding as adverse effect information from the trials. We used odds ratios (OR) and 95% confidence intervals (CI) for effect measures. MAIN RESULTS Sixty trials involving 66,689 patients were included. During PCI (48 trials with 33,513 participants) glycoprotein IIb/IIIa blockers decreased all-cause mortality at 30 days (OR 0.79, 95% CI 0.64 to 0.97) but not at six months (OR 0.90, 95% CI 0.77 to 1.05). All-cause death or myocardial infarction was decreased both at 30 days (OR 0.66, 95% CI 0.60 to 0.72) and at six months (OR 0.75, 95% CI 0.64 to 0.86), although severe bleeding was increased (OR 1.39, 95% CI 1.21 to 1.61; absolute risk increase (ARI) 8.0 per 1000). The efficacy results were homogeneous for every endpoint according to the clinical condition of the patients, but were less marked for patients pre-treated with clopidogrel, especially in patients without acute coronary syndromes.As initial medical treatment of NSTEACS (12 trials with 33,176 participants), IIb/IIIa blockers did not decrease mortality at 30 days (OR 0.90, 95% CI 0.79 to 1.02) or at six months (OR 1.00, 95% CI 0.87 to 1.15), but slightly decreased death or myocardial infarction at 30 days (OR 0.91, 95% CI 0.85 to 0.98) and at six months (OR 0.88, 95% CI 0.81 to 0.96), although severe bleeding was increased (OR 1.29, 95% CI 1.14 to 1.45; ARI 1.4 per 1000). AUTHORS' CONCLUSIONS When administered during PCI, intravenous glycoprotein IIb/IIIa blockers reduce the risk of all-cause death at 30 days but not at six months, and reduce the risk of death or myocardial infarction at 30 days and at six months, at a price of an increase in the risk of severe bleeding. The efficacy effects are homogeneous but are less marked in patients pre-treated with clopidogrel where they seem to be effective only in patients with acute coronary syndromes. When administered as initial medical treatment in patients with NSTEACS, these agents do not reduce mortality although they slightly reduce the risk of death or myocardial infarction.
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Affiliation(s)
- Xavier Bosch
- Department of Cardiology, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Villarroel 170, Barcelona, Spain, 08036
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