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Zhao G, Tang W, Yang C, Liu X, Huang J. The Prognostic Value of Advanced Lung Cancer Inflammation Index in Elderly Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention. Int Heart J 2024; 65:621-629. [PMID: 39010222 DOI: 10.1536/ihj.24-046] [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] [Indexed: 07/17/2024]
Abstract
This study aimed to investigate the predictive value of advanced lung cancer inflammation index (ALI) for major adverse cardiovascular events (MACEs) in elderly patients with acute coronary syndrome (ACS).A total of 586 ACS patients undergoing percutaneous coronary intervention (PCI) over 65 years old between January 2017 and December 2018 were retrospectively collected. The patients were divided into two groups by the optimal cutoff value of ALI. Spearman rank correlation coefficient was used to evaluate the correlation between ALI and the Global Registry of Acute Coronary Events (GRACE). Time-dependent receiver operating characteristic (ROC) curves, Cox survival analysis, and Kaplan Meier curves were used to assess the predictive value of ALI for MACEs.Spearman's nonparametric test revealed a moderate correlation between ALI and the GRACE (r: -0.417, P < 0.001). Time-dependent ROC curves showed that the area under the curve for ALI was 0.751 (95% CI, 0.699-0.798) in predicting MACEs, higher than Geriatric Nutritional Risk Index (0.531, 95% CI 0.435-0.627) and Prognostic Nutritional Index (0.590, 95% CI 0.505-0.676), and for combined diagnostic models (ALI + GRACE) was 0.913, (95% CI 0.875 - 0.942, P < 0.001). Multivariate Cox analysis demonstrated that ALI (HR: 0.974, 95% CI: 0.952-0.996, P = 0.017) was an independent risk factor for MACEs. Kaplan Meier survival analysis showed that the cumulative incidence of MACEs was significantly higher in elderly ACS patients with lower ALI (log-rank test, P < 0.001).ALI could be a nutrition-inflammation indicator with independent predictive value for long-term MACEs of elderly ACS patients after PCI.
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Affiliation(s)
- Guoying Zhao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University
| | - Wenbin Tang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University
| | - Chao Yang
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University
| | - Xiao Liu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University
| | - Jinyu Huang
- Department of Cardiology, Hangzhou First People's Hospital
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Cohen M, Jones C. Patient and Physician Perspectives on the Benefits and Risks of Antiplatelet Therapy for Acute Coronary Syndrome. Cardiol Ther 2024:10.1007/s40119-024-00372-7. [PMID: 38907182 DOI: 10.1007/s40119-024-00372-7] [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: 04/12/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
This article is co-authored by a patient with acute coronary syndrome (ACS) who is receiving long-term antiplatelet therapy in the USA and a cardiologist who routinely treats patients with ACS. The patient describes his experience from diagnosis to the present day and discusses his concerns regarding treatment and management of the condition, including the balance between the benefits and risks of antiplatelet therapy. The patient also describes his work as an advocate for cardiac health. The physician perspective on treating and managing patients with ACS is provided by a cardiologist based in the USA who is and was not involved in this patient's care. The physician reviews the benefits and risks of antiplatelet therapies for the treatment of patients with ACS and discusses his own clinical experience of managing these patients, including how issues such as treatment adherence, as well as the potential inertia to prescribing certain medications that may be seen among physicians, could be overcome.
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Affiliation(s)
- Marc Cohen
- Newark Beth Israel Medical Center, 201 Lyons Avenue at Osborne Terrace, Newark, NJ, USA.
- Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ, USA.
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Wu YJ, Wu CC, Huang HY, Wu CY, Huang CC, Wang CC. Low-dose prasugrel versus standard-dose ticagrelor in east Asian patients with acute coronary syndrome. J Thromb Thrombolysis 2024; 57:537-546. [PMID: 38555552 DOI: 10.1007/s11239-024-02965-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/02/2024]
Abstract
Low-dose prasugrel demonstrated a similar effectiveness profile to clopidogrel in East Asian ACS patients, but its comparison with another new-generation potent P2Y12 inhibitor, ticagrelor, remains unclear. To compare the effectiveness and safety of low-dose prasugrel against those of standard-dose ticagrelor in East Asian patients with ACS. This retrospective cohort study used Taiwan's National Health and Welfare Database. This study included ACS patients who underwent percutaneous coronary intervention and, at discharge between January 1, 2018 and December 31, 2020, were prescribed with low-dose prasugrel plus aspirin or standard-dose ticagrelor plus aspirin. Stabilized inverse probability of treatment weighting was used to balance the covariates across these two groups. The primary effectiveness outcome was a composite of acute myocardial infarction, ischemic stroke, and cardiovascular death; the secondary effectiveness outcome was each of the individual components of the primary outcome, transient ischemic attack, and repeat revascularization. The primary safety outcome was a composite of intracranial hemorrhage and gastrointestinal bleeding, and the two secondary safety outcomes were intracranial hemorrhage and gastrointestinal bleeding. A total of 24,807 patients were included in this study. Among them, 1,493 were low-dose prasugrel users and 23,314 were standard-dose ticagrelor users. No significant differences were found in primary effectiveness [HR: 0.97 (0.74-1.28)] or primary safety outcomes [HR: 1.22 (0.73-2.01)] between the two study groups. For East Asian patients with ACS, low-dose prasugrel provides comparable effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations.
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Affiliation(s)
- Yee-Jen Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan
| | - Hsin-Yi Huang
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan
| | - Chi-Yun Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chuan Wang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan.
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan.
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Mansurova JA, Orekhov A, Zhunuspekova AS, Kassymova AA, Karazhanova LK. The Impact of Patient Adherence to Dual Antiplatelet Medication Following Percutaneous Coronary Intervention on the Occurrence of Adverse Cardiovascular Events. Patient Prefer Adherence 2024; 18:425-434. [PMID: 38384448 PMCID: PMC10880456 DOI: 10.2147/ppa.s450317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/03/2024] [Indexed: 02/23/2024] Open
Abstract
Background The objective of this study is to examine the impact of medication adherence on the timing of non-cardiovascular serious events (NCDS) onset in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). Methods This prospective study was conducted at a single center and involved 220 ACS patients who underwent sequential PCI with stenting. The Morisky Green Levine Medication Adherence Scale was employed to assess adherence to dual antiplatelet therapy (DAPT) and its impact on NCDS occurrence. Early in their hospitalization, all patients received education at the Coronary Heart Disease School. The survival rates of patients in both the main group and a control group (n=355) were subsequently evaluated. Results The study findings indicated an inverse relationship between stent thrombosis development (Rho=-0.334; p=0.001) and the timing of recurrent myocardial ischemia. There was also an inverse correlation between patient adherence and stent thrombosis development (Rho=-0.275; p=0.009). Non-adherent individuals had a 16.8 times higher likelihood of experiencing stent thrombosis compared to compliant patients (p<0.001). Following participation in the CHD School program, treatment adherence increased from 56.5% to 88.2%. Education for ACS patients post-stenting was significantly associated with all-cause mortality within the first 6 months (p=0.040). Conclusion Secondary preventive measures, including education, impact the success of endovascular interventions in both the early hospital phase and the long term. Patient education can serve as a supplementary intervention to enhance DAPT adherence, thus diminishing the risk of recurrent cardiovascular events and mortality post endovascular intervention.
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Affiliation(s)
- J A Mansurova
- Department of Therapy, Non-Commercial Joint-Stock Company “Semey Medical University”, Semey, The Republic of Kazakhstan
| | - Andrey Orekhov
- Department of Therapy, Non-Commercial Joint-Stock Company “Semey Medical University”, Semey, The Republic of Kazakhstan
| | - A S Zhunuspekova
- Department of Therapy, Non-Commercial Joint-Stock Company “Semey Medical University”, Semey, The Republic of Kazakhstan
| | - A A Kassymova
- Department of Therapy, Non-Commercial Joint-Stock Company “Semey Medical University”, Semey, The Republic of Kazakhstan
| | - L K Karazhanova
- Department of Therapy, Non-Commercial Joint-Stock Company “Semey Medical University”, Semey, The Republic of Kazakhstan
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Lee M, Byun S, Lim S, Choo EH, Lee KY, Moon D, Choi IJ, Hwang BH, Kim CJ, Park MW, Choi YS, Kim HY, Yoo KD, Jeon DS, Yim HW, Chang K. Dual Antiplatelet Therapy De-Escalation in Stabilized Myocardial Infarction With High Ischemic Risk: Post Hoc Analysis of the TALOS-AMI Randomized Clinical Trial. JAMA Cardiol 2024; 9:125-133. [PMID: 38117483 PMCID: PMC10733848 DOI: 10.1001/jamacardio.2023.4587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 10/12/2023] [Indexed: 12/21/2023]
Abstract
Importance In patients with acute myocardial infarction (AMI) who have high ischemic risk, data on the efficacy and safety of the de-escalation strategy of switching from ticagrelor to clopidogrel are lacking. Objective To evaluate the outcomes of the de-escalation strategy compared with dual antiplatelet therapy (DAPT) with ticagrelor in stabilized patients with AMI and high ischemic risk following percutaneous coronary intervention (PCI). Design, Setting, and Participants This was a post hoc analysis of the Ticagrelor vs Clopidogrel in Stabilized Patients With Acute Myocardial Infarction (TALOS-AMI) trial, an open-label, assessor-blinded, multicenter, randomized clinical trial. Patients with AMI who had no event during 1 month of ticagrelor-based DAPT after PCI were included. High ischemic risk was defined as having a history of diabetes or chronic kidney disease, multivessel PCI, at least 3 lesions treated, total stent length greater than 60 mm, at least 3 stents implanted, left main PCI, or bifurcation PCI with at least 2 stents. Data were collected from February 14, 2014, to January 21, 2021, and analyzed from December 1, 2021, to June 30, 2022. Intervention Patients were randomly assigned to either de-escalation from ticagrelor to clopidogrel or ticagrelor-based DAPT. Main Outcomes and Measures Ischemic outcomes (composite of cardiovascular death, myocardial infarction, ischemic stroke, ischemia-driven revascularization, or stent thrombosis) and bleeding outcomes (Bleeding Academic Research Consortium type 2, 3, or 5 bleeding) were evaluated. Results Of 2697 patients with AMI (mean [SD] age, 60.0 [11.4] years; 454 [16.8%] female), 1371 (50.8%; 684 assigned to de-escalation and 687 assigned to ticagrelor-based DAPT) had high ischemic risk features and a significantly higher risk of ischemic outcomes than those without high ischemic risk (1326 patients [49.2%], including 665 assigned to de-escalation and 661 assigned to ticagrelor-based DAPT) (hazard ratio [HR], 1.74; 95% CI, 1.15-2.63; P = .01). De-escalation to clopidogrel, compared with ticagrelor-based DAPT, showed no significant difference in ischemic risk across the high ischemic risk group (HR, 0.88; 95% CI, 0.54-1.45; P = .62) and the non-high ischemic risk group (HR, 0.65; 95% CI, 0.33-1.28; P = .21), without heterogeneity (P for interaction = .47). The bleeding risk of the de-escalation group was consistent in both the high ischemic risk group (HR, 0.64; 95% CI, 0.37-1.11; P = .11) and the non-high ischemic risk group (HR, 0.42; 95% CI, 0.24-0.75; P = .003), without heterogeneity (P for interaction = .32). Conclusions and Relevance In stabilized patients with AMI, the ischemic and bleeding outcomes of an unguided de-escalation strategy with clopidogrel compared with a ticagrelor-based DAPT strategy were consistent without significant interaction, regardless of the presence of high ischemic risk.
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Affiliation(s)
- Myunhee Lee
- Division of Cardiology, Department of Internal Medicine, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungwook Byun
- Division of Cardiology, Department of Internal Medicine, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Ho Choo
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kwan Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Donggyu Moon
- Division of Cardiology, Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yun Seok Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, St Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Doo-Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyeon Woo Yim
- Department of Preventive Medicine, Clinical Research Coordinating Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kiyuk Chang
- Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Cortés P, Zeng JJ, Karime C, Lewis MD, Gharacholou SM, Antwi SO, Pang M. Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention. Gastrointest Endosc 2024; 99:10-20.e6. [PMID: 37579980 DOI: 10.1016/j.gie.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND AND AIMS The management of dual anti-platelet therapy after percutaneous coronary intervention (PCI) and GI bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of GIB and recurrent bleeding and to determine whether recurrent bleeding increases the risk of major adverse cardiovascular events (MACEs). METHODS In this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were GIB at 180 days and recurrent bleeding or MACE at 365 days. Logistic regression was used to identify predictors of GIB and recurrent bleeding. Cox proportional hazards modeling was used to determine whether recurrent bleeding can predict a MACE. RESULTS Five hundred thirty-six patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with a 95% increased odds of GIB (P < .001). The P2Y12 inhibitor was continued in >90% of patients, which trended toward significance for recurrent bleeding (P < .10). The HAS-BLED score (Hypertension, Abnormal renal and liver function, Stroke, Bleeding tendency or predisposition, Labile INRs, Elderly, Drugs), including a labile international normalized ratio and prior major bleeding, was strongly associated with recurrent bleeding (P ≤ .009). Recurrent bleeding was associated with a 115% increased risk of MACEs (P = .02). We derived a novel risk score, named the SIGE score ([S]TEMI at PCI, having a labile [I]NR at PCI, index [G]IB within 180 days of PCI, and previous precatheterization [E]ndoscopy within 6 months), to predict recurrent bleeding at 365 days with a high predictive accuracy (area under the curve, .773; 95% confidence interval, .702-.845). CONCLUSIONS The SIGE score may help to predict recurrent bleeding, which was shown to be associated with an increased risk of MACEs. Further external validation is needed.
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Affiliation(s)
- Pedro Cortés
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Jennifer J Zeng
- Krieger School of Arts & Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christian Karime
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michele D Lewis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Samuel O Antwi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Maoyin Pang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Alharbi A, Mhanna M, Alyosif M, Pena C, Jabr A, Alsughayer A, Alfatlawi H, Safi M, Aldhafeeri A, Patel N, Khuder S, Eltahawy E. Safety and Efficacy of Direct Oral Anticoagulant in Addition to Antiplatelet Therapy After Acute Coronary Syndrome: A Systemic Review and Meta-analysis of 53,869 Patients. Clin Ther 2024; 46:e1-e6. [PMID: 37880055 DOI: 10.1016/j.clinthera.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 08/17/2023] [Accepted: 09/29/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Significant progress has been made in the management of patients with acute coronary syndrome (ACS) during the past few decades. However, the role of direct oral anticoagulants (DOACs) in post-ACS prophylactic therapy remains unknown. This study aims to assess the efficacy and safety of DOACs plus antiplatelet treatment (APT) after ACS. METHODS A systematic literature search was conducted to identify randomized clinical trials comparing DOACs plus APT with APT alone after ACS. The primary efficacy end points were cardiovascular mortality, myocardial infarction, all-cause mortality, and stroke and systemic embolization (SSE). The primary safety end point was major bleeding. The random-effects model was used to calculate relative risk (RR) and corresponding 95% CIs. RESULTS Nine trials with a total of 53,869 patients were identified, with 33,011 (61.2%) in the DOACs plus APT group and 20,858 (38.8%) in the APT alone group. The use of DOACs did not decrease the risk of cardiovascular death (RR = 0.87; 95% CI, 0.75-1.01; P = 0.08; I2 = 0%) or myocardial infarction (RR = 0.90; 95% CI, 0.80-1.02; P = 0.10; I2 = 6%). However, the risk of SSE was significantly lower in patients who received DOACs plus APT compared with APT alone (RR = 0.67; 95% CI, 0.50-0.90; P = 0.008). Moreover, all-cause mortality was significantly lower in the DOACs plus APT group (RR = 0.83; 95% CI, 0.71-98; P = 0.03; I2 = 0%). However, the risk of major bleeding was significantly higher in patients treated with DOACs plus APT compared with APT alone (RR = 2.53; 95% CI, 1.96-3.26; P < 0.01; I2 = 0%), as was the risk of nonmajor bleeding (RR = 2.27; 95% CI, 1.51-3.41; P < 0.01). IMPLICATIONS DOACs plus APT for the prevention of left ventricular thrombus in patients with ACS were associated with a lower risk of SSE and all-cause mortality but increased the risk of major and nonmajor bleeding. The benefits and risks of this approach should be weighed based on a patient's individual clinical characteristics.
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Affiliation(s)
- Abdulmajeed Alharbi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio.
| | - Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Mohammed Alyosif
- Department of Cardiology, University of Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Clarissa Pena
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abed Jabr
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Anas Alsughayer
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Halah Alfatlawi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Mohammad Safi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abdulaziz Aldhafeeri
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Neha Patel
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Sadik Khuder
- Department of Medicine, Statistics, and Public Health, College of Medicine and Life Sciences, The University of Toledo, Toledo, Ohio
| | - Ehab Eltahawy
- Department of Cardiology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
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Baaten CCFMJ, Nagy M, Bergmeier W, Spronk HMH, van der Meijden PEJ. Platelet biology and function: plaque erosion vs. rupture. Eur Heart J 2024; 45:18-31. [PMID: 37940193 PMCID: PMC10757869 DOI: 10.1093/eurheartj/ehad720] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023] Open
Abstract
The leading cause of heart disease in developed countries is coronary atherosclerosis, which is not simply a result of ageing but a chronic inflammatory process that can lead to acute clinical events upon atherosclerotic plaque rupture or erosion and arterial thrombus formation. The composition and location of atherosclerotic plaques determine the phenotype of the lesion and whether it is more likely to rupture or to erode. Although plaque rupture and erosion both initiate platelet activation on the exposed vascular surface, the contribution of platelets to thrombus formation differs between the two phenotypes. In this review, plaque phenotype is discussed in relation to thrombus composition, and an overview of important mediators (haemodynamics, matrix components, and soluble factors) in plaque-induced platelet activation is given. As thrombus formation on disrupted plaques does not necessarily result in complete vessel occlusion, plaque healing can occur. Therefore, the latest findings on plaque healing and the potential role of platelets in this process are summarized. Finally, the clinical need for more effective antithrombotic agents is highlighted.
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Affiliation(s)
- Constance C F M J Baaten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, the Netherlands
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Aachen, Germany
| | - Magdolna Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, the Netherlands
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, School of Medicine, University of North Caroline at Chapel Hill, Chapel Hill, NC, USA
- Blood Research Center, School of Medicine, University of North Caroline at Chapel Hill, Chapel Hill, NC, USA
| | - Henri M H Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, the Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
- Thrombosis Expertise Center, Heart+ Vascular Center, Maastricht University Medical Center+, P. Debeyelaan 25, Maastricht, the Netherlands
| | - Paola E J van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, the Netherlands
- Thrombosis Expertise Center, Heart+ Vascular Center, Maastricht University Medical Center+, P. Debeyelaan 25, Maastricht, the Netherlands
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Gragnano F, Capolongo A, Micari A, Costa F, Garcia-Ruiz V, De Sio V, Terracciano F, Cesaro A, Moscarella E, Coletta S, Raucci P, Fimiani F, De Luca L, Gargiulo G, Andò G, Calabrò P. Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. J Clin Med 2023; 13:98. [PMID: 38202105 PMCID: PMC10780105 DOI: 10.3390/jcm13010098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
The antithrombotic management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) poses numerous challenges. Triple antithrombotic therapy (TAT), which combines dual antiplatelet therapy (DAPT) with oral anticoagulation (OAC), provides anti-ischemic protection but increases the risk of bleeding. Therefore, TAT is generally limited to a short phase (1 week) after PCI, followed by aspirin withdrawal and continuation of 6-12 months of dual antithrombotic therapy (DAT), comprising OAC plus clopidogrel, followed by OAC alone. This pharmacological approach has been shown to mitigate bleeding risk while preserving adequate anti-ischemic efficacy. However, the decision-making process remains complex in elderly patients and those with co-morbidities, significantly influencing ischemic and bleeding risk. In this review, we discuss the available evidence in this area from randomized clinical trials and meta-analyses for post-procedural antithrombotic therapies in patients with non-valvular AF undergoing PCI.
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | | | - Vincenzo De Sio
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabrizia Terracciano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Silvio Coletta
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Pasquale Raucci
- Division of Health Technology Assessment, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, Azienda Ospedaliera di Rilievo Nazionale Dei Colli, “Vincenzo Monaldi”, CCMR Regione Campania, 80138 Naples, Italy;
| | - Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, 00152 Roma, Italy;
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
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10
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Kim MC, Ahn SG, Cho KH, Sim DS, Hong YJ, Kim JH, Jeong MH, Lee JW, Youn YJ, Kim HY, Yoo KD, Jeon DS, Shin ES, Jeong YH, Chang K, Ahn Y. De-escalation from ticagrelor to clopidogrel in patients with acute myocardial infarction: the TALOS-AMI HBR substudy. EUROINTERVENTION 2023; 19:e832-e843. [PMID: 37724337 PMCID: PMC10687647 DOI: 10.4244/eij-d-23-00427] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND The benefits of de-escalation of P2Y12 inhibition after percutaneous coronary intervention (PCI) may differ by high bleeding risk (HBR) status. AIMS We investigated the efficacy and safety of de-escalation from ticagrelor to clopidogrel after PCI by HBR status. METHODS This is a non-prespecified post hoc analysis of the TicAgrelor Versus CLOpidogrel in Stabilized Patients with Acute Myocardial Infarction (TALOS-AMI) trial. Net adverse clinical events (a composite of cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium [BARC] bleeding type 2, 3, or 5) at 1 year post-PCI were compared between the de-escalation (clopidogrel plus aspirin) and the active control (ticagrelor plus aspirin) groups by HBR status, as defined by the modification of the Academic Research Consortium (ARC) criteria. RESULTS A total of 2,625 patients in the TALOS-AMI trial were analysed. Of these, 589 (22.4%) met the modified ARC-HBR criteria. The de-escalation group had lower primary endpoint rates than the control group in both HBR (hazard ratio [HR] 0.47, 95% confidence interval [CI]: 0.26-0.84) and non-HBR (HR 0.59, 95% CI: 0.41-0.84) patients. There were no differences in treatment effect for the primary endpoint regardless of HBR status (p for interaction=0.904). BARC bleeding type 3 or 5 was less common in the de-escalation than the control group among HBR patients only (HR 0.24, 95% CI: 0.07-0.84). CONCLUSIONS In stabilised acute myocardial infarction patients, unguided de-escalation from ticagrelor to clopidogrel was associated with a lower rate of net adverse clinical outcomes irrespective of HBR status. The effect of de-escalation of P2Y12 inhibition on reducing haemorrhagic events was greater in patients with HBR.
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Affiliation(s)
- Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Kyung Hoon Cho
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Doo Sun Sim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Young Joon Hong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Ju Han Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Jun-Won Lee
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Young-Jin Youn
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Wonju, South Korea
| | - Hee-Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St Mary's Hospital, Bucheon, South Korea
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, St Vincent's Hospital, Suwon, South Korea
| | - Doo-Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St Mary's Hospital, Incheon, South Korea
| | - Eun-Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Young-Hoon Jeong
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, South Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Seoul St Mary's Hospital, Seoul, South Korea
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
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11
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Wongsalap Y, Kengkla K, Wilairat P, Ratworawong K, Saokaew S, Wanlapakorn C. Efficacy and safety of different dual antiplatelet strategies in patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis. Chronic Dis Transl Med 2023; 9:299-308. [PMID: 37915393 PMCID: PMC10617309 DOI: 10.1002/cdt3.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/26/2023] [Accepted: 06/26/2023] [Indexed: 11/03/2023] Open
Abstract
Background Dual antiplatelet therapy (DAPT) is key for preventing ischaemic events post-percutaneous coronary intervention (PCI). Various DAPT modifications like the shortened duration or P2Y12 inhibitor (P2Y12i) de-escalation are implemented to reduce bleeding risk. However, these strategies lack direct comparative studies. This study aimed to assess the efficacy and safety of such DAPT strategies, including de-escalated and short DAPT, in patients undergoing PCI. Methods We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases for relevant randomized controlled trials (RCTs). We performed a network meta-analysis (NMA) to estimate risk ratios (RRs) and 95% confidence intervals (CIs). The primary efficacy endpoint was major adverse cardiac events (MACEs), and the primary safety endpoint was major bleeding. Secondary endpoints included individual components of MACEs and net adverse clinical events (NACEs). Results A total of 17 RCTs comprising 53,156 patients (median age, 62.0 years, 24.8% female) were included. NMA suggested that de-escalation DAPT was associated with a significantly lower risk of MACEs (risk ratio [RR] = 0.79, 95% confidence interval [CI] = 0.64-0.98), bleeding (RR = 0.63, 95% CI = 0.49-0.82), and NACEs (RR = 0.69, 95% CI = 0.60-0.79) compared with standard DAPT. Short DAPT followed by P2Y12i monotherapy exhibited a significantly decreased risk of major bleeding (RR = 0.63, 95% CI = 0.46-0.86) compared with standard DAPT. Conclusions De-escalation DAPT was the most effective strategy for preventing the risk of MACEs without increasing bleeding events, while short DAPT followed by P2Y12i monotherapy was the most effective strategy for reducing the risk of bleeding among patients undergoing PCI.
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Affiliation(s)
- Yuttana Wongsalap
- Division of Clinical Pharmacy, Department of Pharmaceutical CareUniversity of PhayaoPhayaoThailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
- Unit of Excellence on Clinical Outcomes Research and Integration (UNICORN), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
| | - Kirati Kengkla
- Division of Clinical Pharmacy, Department of Pharmaceutical CareUniversity of PhayaoPhayaoThailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
- Unit of Excellence on Clinical Outcomes Research and Integration (UNICORN), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
| | - Preyanate Wilairat
- Division of Clinical Pharmacy, Department of Pharmaceutical CareUniversity of PhayaoPhayaoThailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
- Unit of Excellence on Clinical Outcomes Research and Integration (UNICORN), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
| | - Khemanat Ratworawong
- Division of Clinical Pharmacy, Department of Pharmaceutical CareUniversity of PhayaoPhayaoThailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
- Unit of Excellence on Clinical Outcomes Research and Integration (UNICORN), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
- Unit of Excellence on Clinical Outcomes Research and Integration (UNICORN), School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
- Division of Social and Administrative Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical SciencesUniversity of PhayaoPhayaoThailand
| | - Chaisiri Wanlapakorn
- Cardiac Centre, King Chulalongkorn Memorial HospitalKrung Thep Maha NakornThailand
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12
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Jang MH, Kim AR, Kim T, Oh HJ, Lee JH, Lee YJ, Kim S, Lee J, Kim JH, Cha SJ, Kim TO, Kang DY, Lee PH, Ahn JM, Park DW, Park SJ. Age- and Sex-Specific Disparities in Outcomes After Ticagrelor Versus Clopidogrel in East Asian Patients. Am J Cardiol 2023; 207:237-244. [PMID: 37757520 DOI: 10.1016/j.amjcard.2023.08.124] [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: 05/29/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023]
Abstract
It is unknown whether there are age- and gender-related differences in the safety and efficacy of potent P2Y12 inhibitors in East Asian populations with a different bleeding or ischemic propensity. Using data from the TICAKOREA (Ticagrelor Versus Clopidogrel in Asian/Korean Patients with ACS Intended for Invasive Management) trial comparing ticagrelor versus clopidogrel for 800 Korean patients with acute coronary syndrome, the safety and efficacy outcomes were compared according to age (<75 vs ≥75 years) and gender (men vs women). The primary bleeding end point was clinically significant bleeding, and the primary ischemic end point was a major adverse cardiovascular event (MACE) at 12 months. The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in patients aged <75 years (adjusted hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.40 to 4.67) but not in patients aged ≥75 years (adjusted HR 1.1, 95% CI 0.40 to 3.38). The incidences of MACEs were significantly higher after ticagrelor than after clopidogrel in patients aged ≥75 years (adjusted HR 6.14, 95% CI 1.40 to 26.90) but not in patients aged <75 years (adjusted HR 0.93, 95% CI 0.50 to 1.73). The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in men (adjusted HR 2.69, 95% CI 1.38 to 5.24) but not in women (adjusted HR 1.49, 95% CI 0.64 to 3.46). The adjusted risks of MACEs after ticagrelor or clopidogrel were not significantly different between men and women. In conclusion, there were substantial age- and gender-related differences in bleeding and ischemic outcomes after ticagrelor or clopidogrel in Korean patients with acute coronary syndrome. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique identifier: NCT02094963.
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Affiliation(s)
- Mi Hee Jang
- Department of Cardiology, Ulsan University Hospital, Ulsan, Korea
| | - Ah-Ram Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taesun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon Jeong Oh
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeen Hwa Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Jeong Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyeon Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Joo Cha
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Saito T, Fujisaki T, Aikawa T, Kampaktsis PN, Malik A, Briasoulis A, Takagi H, Wiley J, Slipczuk L, Kuno T. Strategy of dual antiplatelet therapy for patients with ST-elevation myocardial infarction and non-ST-elevation acute coronary syndromes: A systematic review and network meta-analysis. Int J Cardiol 2023; 389:131157. [PMID: 37433404 DOI: 10.1016/j.ijcard.2023.131157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/06/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Various durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown. METHODS PubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y12 inhibitors, short-term DAPT (≤6 months) followed by potent P2Y12 inhibitors or aspirin, unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events. RESULTS Twenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y12 inhibitors (HR:0.57; 95% CI:0.34-0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47-0.90), standard DAPT using potent P2Y12 inhibitors (HR:0.62; 95% CI:0.50-0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55-0.98) without increased risk of MACE. CONCLUSION Unguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.
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Affiliation(s)
- Tetsuya Saito
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadao Aikawa
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Polydoros N Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, United States of America
| | - Aaqib Malik
- Department of Cardiology, Westchester Medical Center, NY, United States of America
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart failure and Transplantation, University of Iowa, IA, United States of America
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, LA, United States of America
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, United States of America
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, United States of America; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, NY, United States of America.
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14
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Yang M, Su W, Li H, Li L, An Z, Xiao F, Liu Y, Zhang X, Liu X, Guo H, Li A. Association of per- and polyfluoroalkyl substances with hepatic steatosis and metabolic dysfunction-associated fatty liver disease among patients with acute coronary syndrome. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2023; 264:115473. [PMID: 37722302 DOI: 10.1016/j.ecoenv.2023.115473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023]
Abstract
Etiology of hepatic steatosis and metabolic dysfunction-associated fatty liver disease (MAFLD) among acute coronary syndrome (ACS) remains unclear. Existing studies suggested the potential role of per- and polyfluoroalkyl substances (PFAS) in comorbidity of hepatic steatosis among ACS patients. Therefore, we conducted a cross-sectional study based on the ACS inpatients to assess the associations of plasma PFAS congeners and mixtures with hepatic steatosis and MAFLD. This study included 546 newly diagnosed ACS patients. Twelve PFAS were quantified using ultra-high-performance liquid chromatography-tandem mass spectrometry. Hepatic steatosis was defined by hepatic steatosis index (HSI). MAFLD was defined as the combination of hepatic steatosis based on the risk factor calculation with metabolic abnormalities. Generalized linear model was used to examine the associations of PFAS congeners with HSI and MAFLD. Adaptive elastic net (AENET) was further used for PFAS congeners selection. Mixture effects were also assessed with Bayesian kernel machine regression model (BKMR). Congeners analysis observed significant greater percent change of HSI for each doubling in PFOS (1.82%, 95% CI: 0.87%, 2.77%), PFHxS (1.17%, 95% CI: 0.46%, 1.89%) and total PFAS (1.84%, 95% CI: 0.56%, 3.14%). Moreover, each doubling in PFOS (OR=1.42, 95% CI: 1.13, 1.81), PFHxS (OR=1.31, 95% CI: 1.09, 1.59) and total PFAS (OR=1.43, 95% CI: 1.06, 1.94) was associated with increased risk of MAFLD. In AENET regression, only PFOS presented significant positive associations with HSI. Mixture analysis indicated significant positive associations between PFAS mixtures and HSI. This is the first study to demonstrate associations of PFAS congeners and mixtures with hepatic steatosis and MAFLD among ACS patients, which provides hypothesis into the mechanisms behind comorbidity of hepatic steatosis among ACS patients, as well as tertiary prevention of ACS.
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Affiliation(s)
- Ming Yang
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing 100005, PR China; Center of Environmental and Health Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100005, PR China
| | - Weitao Su
- Department of Epidemiology and Health Statistics, School of Public Health, Fujian Medical University, Fuzhou, PR China
| | - Haoran Li
- Department of Toxicology, School of Public Health, Hebei Medical University, Shijiazhuang 050017, PR China; Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, PR China
| | - Longfei Li
- Department of Toxicology, School of Public Health, Hebei Medical University, Shijiazhuang 050017, PR China; Hebei Key Laboratory of Environment and Human Health, Hebei Province, Shijiazhuang 050017, PR China
| | - Ziwen An
- Department of Toxicology, School of Public Health, Hebei Medical University, Shijiazhuang 050017, PR China; Hebei Key Laboratory of Environment and Human Health, Hebei Province, Shijiazhuang 050017, PR China
| | - Fang Xiao
- Department of Toxicology, School of Public Health, Hebei Medical University, Shijiazhuang 050017, PR China; Hebei Key Laboratory of Environment and Human Health, Hebei Province, Shijiazhuang 050017, PR China
| | - Yi Liu
- Department of Toxicology, School of Public Health, Hebei Medical University, Shijiazhuang 050017, PR China; Hebei Key Laboratory of Environment and Human Health, Hebei Province, Shijiazhuang 050017, PR China
| | - Xiaoguang Zhang
- Core Facilities and Centers of Hebei Medical University, Shijiazhuang 050017, PR China
| | - Xuehui Liu
- Hebei Key Laboratory of Environment and Human Health, Hebei Province, Shijiazhuang 050017, PR China
| | - Huicai Guo
- Department of Toxicology, School of Public Health, Hebei Medical University, Shijiazhuang 050017, PR China; Hebei Key Laboratory of Environment and Human Health, Hebei Province, Shijiazhuang 050017, PR China.
| | - Ang Li
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing 100005, PR China; Center of Environmental and Health Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100005, PR China.
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15
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Amezcua-Castillo E, González-Pacheco H, Sáenz-San Martín A, Méndez-Ocampo P, Gutierrez-Moctezuma I, Massó F, Sierra-Lara D, Springall R, Rodríguez E, Arias-Mendoza A, Amezcua-Guerra LM. C-Reactive Protein: The Quintessential Marker of Systemic Inflammation in Coronary Artery Disease-Advancing toward Precision Medicine. Biomedicines 2023; 11:2444. [PMID: 37760885 PMCID: PMC10525787 DOI: 10.3390/biomedicines11092444] [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: 07/21/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023] Open
Abstract
Atherosclerotic cardiovascular disease (CVD) remains the leading cause of mortality worldwide. While conventional risk factors have been studied and managed, CVD continues to pose a global threat. Risk scoring systems based on these factors have been developed to predict acute coronary syndromes and guide therapeutic interventions. However, traditional risk algorithms may not fully capture the complexities of individual patients. Recent research highlights the role of inflammation, particularly chronic low-grade inflammation, in the pathogenesis of coronary artery disease (CAD). C-reactive protein (CRP) is an inflammatory molecule that has demonstrated value as a predictive marker for cardiovascular risk assessment, both independently and in conjunction with other parameters. It has been incorporated into risk assessment algorithms, enhancing risk prediction and guiding therapeutic decisions. Pharmacological interventions with anti-inflammatory properties, such as statins, glucagon-like peptide-1 agonists, and interleukin-1 inhibitors, have shown promising effects in reducing both cardiovascular risks and CRP levels. This manuscript provides a comprehensive review of CRP as a marker of systemic inflammation in CAD. By exploring the current knowledge surrounding CRP and its implications for risk prediction and therapeutic interventions, this review contributes to the advancement of personalized cardiology and the optimization of patient care.
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Affiliation(s)
- Emanuel Amezcua-Castillo
- Escuela Nacional Preparatoria No. 6 Antonio Caso, Universidad Nacional Autónoma de México, Mexico City 04100, Mexico;
| | - Héctor González-Pacheco
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (H.G.-P.); (D.S.-L.); (A.A.-M.)
| | - Arturo Sáenz-San Martín
- School of Medicine, Universidad Autónoma Metropolitana–Xochimilco, Mexico City 14387, Mexico; (A.S.-S.M.); (P.M.-O.); (I.G.-M.)
| | - Pablo Méndez-Ocampo
- School of Medicine, Universidad Autónoma Metropolitana–Xochimilco, Mexico City 14387, Mexico; (A.S.-S.M.); (P.M.-O.); (I.G.-M.)
| | - Iván Gutierrez-Moctezuma
- School of Medicine, Universidad Autónoma Metropolitana–Xochimilco, Mexico City 14387, Mexico; (A.S.-S.M.); (P.M.-O.); (I.G.-M.)
| | - Felipe Massó
- Translational Research Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (F.M.); (E.R.)
| | - Daniel Sierra-Lara
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (H.G.-P.); (D.S.-L.); (A.A.-M.)
| | - Rashidi Springall
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
| | - Emma Rodríguez
- Translational Research Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (F.M.); (E.R.)
| | - Alexandra Arias-Mendoza
- Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (H.G.-P.); (D.S.-L.); (A.A.-M.)
| | - Luis M. Amezcua-Guerra
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
- Health Care Department, Universidad Autónoma Metropolitana–Xochimilco, Mexico City 14387, Mexico
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16
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Lancellotti P, Aqil A, Musumeci L, Jacques N, Ditkowski B, Debuisson M, Thiry M, Dupont J, Gougnard A, Sandersen C, Cheramy-Bien JP, Sakalihasan N, Nchimi A, Detrembleur C, Jérôme C, Oury C. Bioactive surface coating for preventing mechanical heart valve thrombosis. J Thromb Haemost 2023; 21:2485-2498. [PMID: 37196847 DOI: 10.1016/j.jtha.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Prosthetic heart valves are the only treatment for most patients with severe valvular heart disease. Mechanical valves, made of metallic components, are the most long-lasting type of replacement valves. However, they are prone to thrombosis and require permanent anticoagulation and monitoring, which leads to higher risk of bleeding and impacts the patient's quality of life. OBJECTIVES To develop a bioactive coating for mechanical valves with the aim to prevent thrombosis and improve patient outcomes. METHODS We used a catechol-based approach to produce a drug-releasing multilayer coating adherent to mechanical valves. The hemodynamic performance of coated Open Pivot valves was verified in a heart model tester, and coating durability in the long term was assessed in a durability tester producing accelerated cardiac cycles. Coating antithrombotic activity was evaluated in vitro with human plasma or whole blood under static and flow conditions and in vivo after surgical valve implantation in a pig's thoracic aorta. RESULTS We developed an antithrombotic coating consisting of ticagrelor- and minocycline-releasing cross-linked nanogels covalently linked to polyethylene glycol. We demonstrated the hydrodynamic performance, durability, and hemocompatibility of coated valves. The coating did not increase the contact phase activation of coagulation, and it prevented plasma protein adsorption, platelet adhesion, and thrombus formation. Implantation of coated valves in nonanticoagulated pigs for 1 month efficiently reduced valve thrombosis compared with noncoated valves. CONCLUSION Our coating efficiently inhibited mechanical valve thrombosis, which might solve the issues of anticoagulant use in patients and the number of revision surgeries due to valve thrombosis despite anticoagulation.
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Affiliation(s)
- Patrizio Lancellotti
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Abdelhafid Aqil
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Lucia Musumeci
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Nicolas Jacques
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Bartosz Ditkowski
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Margaux Debuisson
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Marc Thiry
- Laboratory of Cellular and Tissular Biology, GIGA-Neurosciences, Cell Biology, University of Liège, Liège, Belgium
| | - Julien Dupont
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Alexandra Gougnard
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Charlotte Sandersen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Jean-Paul Cheramy-Bien
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire of Liège, University of Liège, Liège, Belgium; Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire of Liège, University of Liège, Liège, Belgium; Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Christophe Detrembleur
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Christine Jérôme
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Cécile Oury
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium.
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17
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Spagnolo M, Angiolillo DJ, Capodanno D. Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration. Expert Opin Drug Metab Toxicol 2023; 19:769-784. [PMID: 37849294 DOI: 10.1080/17425255.2023.2272595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption. AREAS COVERED This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023. EXPERT OPINION Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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18
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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19
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Gragnano F, Capolongo A, Terracciano F, De Sio V, Maddaluna P, Fimiani F, Moscarella E, Cesaro A, Montone RA, Bianco R, Lisi D, Mensorio MM, Annecchiarico A, Calabrò P. De-escalation strategies in patients with acute coronary syndrome: a step towards precision medicine. Expert Rev Cardiovasc Ther 2023. [PMID: 37267100 DOI: 10.1080/14779072.2023.2221851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/01/2023] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is a cornerstone in the treatment of patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Current international guidelines recommend the use of 12 months of DAPT with newer P2Y12 inhibitors (i.e. ticagrelor or prasugrel) as first-line therapy in this setting. However, intense and prolonged DAPT regimens are associated with an increased risk of bleeding, with relevant prognostic implications. Recently, a strategy of de-escalation of P2Y12 inhibitors has been proposed as an alternative to conventional DAPT to mitigate the risk of bleeding while preserving ischemic protection after ACS. AREAS COVERED In this review, we summarize the available evidence on guided and unguided strategies for P2Y12 inhibitor de-escalation in patients with ACS undergoing PCI. EXPERT OPINION Among patients with ACS, guided and unguided de-escalation strategies are safe and effective for secondary cardiovascular prevention. Although the implementation of genetic and platelet function tests is of interest for treatment personalization, the routine use of guided de-escalation strategies seems impractical. In this context, unguided de-escalation approaches appear more attractive, convenient, and suitable for contemporary practice.
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Fabrizia Terracciano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | - Vincenzo De Sio
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | - Pasquale Maddaluna
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, AORN Dei Colli "V. Monaldi", Naples, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | - Rocco A Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberto Bianco
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Danilo Lisi
- UOC Risk Management, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | - Mario Massimo Mensorio
- UOC Organizzazione E Programmazione Dei Servizi Ospedalieri E Sanitari, AORN "Sant'anna E San Sebastiano", Caserta, Italy
| | | | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy
- Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy
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20
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Angiolillo DJ, Erlinge D, Ferreiro JL, Gale CP, Huber K, Musumeci G, Collet JP. European practice patterns for antiplatelet management in NSTE-ACS patients: Results from the REal-world ADoption survey focus on acute antiPlatelet treatment (READAPT) survey. Int J Cardiol 2023:S0167-5273(23)00717-9. [PMID: 37201617 DOI: 10.1016/j.ijcard.2023.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/08/2023] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The 2020 European Society of Cardiology (ESC) guidelines for the diagnosis and management of patients with non-ST elevation-acute coronary syndrome (NSTE-ACS) recommend early invasive coronary angiography in high-risk patients and no routine pre-treatment with oral P2Y12 receptor inhibitor in NSTE-ACS patients prior to defining coronary anatomy. OBJECTIVE To assess the implementation of this recommendation in the real-life setting. METHODS A web-survey in 17 European countries collected physician profiles and their perceptions of the diagnosis, medical and invasive management of NSTE-ACS patients at their hospital. A sample size of at least 1100 responders permitted the estimation of proportions with a precision of at least ±3.0%. RESULTS Among the 3024 targeted participants, 1154 provided valid feedback defined as a 50% response rate of answers to the survey questions. Overall, >60% of the participants declared full implementation of the guidelines at their institution. The time delay from admission to coronary angiography and PCI was reported to be <24 h in over 75% of the hospitals while pre-treatment was intended in >50% of NSTE-ACS patients. Ad-hoc percutaneous coronary intervention (PCI) was performed in >70% of the cases while intravenous platelet inhibition was rarely used (<10%). Between countries differences in practice patterns for antiplatelet management for NSTE-ACS were observed, suggesting heterogeneous implementation of the guidelines. CONCLUSIONS This survey indicates that the implementation of 2020 NSTE-ACS guidelines on early invasive management and pre-treatment is heterogeneous, potentially due by local logistical constraints.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - José Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain; Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL); L'Hospitalet de Llobregat, Spain
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trusts, Leeds, UK
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Sigmund Freud University, Medical School, Vienna, Austria
| | - Giuseppe Musumeci
- Cardiology Division, Ospedale Mauriziano, Torino, Italy; Past President Italian Society of Interventional Cardiology (GISE), Italy
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris 75013, France
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21
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Cimmino G, Conte S, Palumbo D, Sperlongano S, Torella M, Della Corte A, Golino P. The Novel Role of Noncoding RNAs in Modulating Platelet Function: Implications in Activation and Aggregation. Int J Mol Sci 2023; 24:ijms24087650. [PMID: 37108819 PMCID: PMC10144470 DOI: 10.3390/ijms24087650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
It is currently believed that plaque complication, with the consequent superimposed thrombosis, is a key factor in the clinical occurrence of acute coronary syndromes (ACSs). Platelets are major players in this process. Despite the considerable progress made by the new antithrombotic strategies (P2Y12 receptor inhibitors, new oral anticoagulants, thrombin direct inhibitors, etc.) in terms of a reduction in major cardiovascular events, a significant number of patients with previous ACSs treated with these drugs continue to experience events, indicating that the mechanisms of platelet remain largely unknown. In the last decade, our knowledge of platelet pathophysiology has improved. It has been reported that, in response to physiological and pathological stimuli, platelet activation is accompanied by de novo protein synthesis, through a rapid and particularly well-regulated translation of resident mRNAs of megakaryocytic derivation. Although the platelets are anucleate, they indeed contain an important fraction of mRNAs that can be quickly used for protein synthesis following their activation. A better understanding of the pathophysiology of platelet activation and the interaction with the main cellular components of the vascular wall will open up new perspectives in the treatment of the majority of thrombotic disorders, such as ACSs, stroke, and peripheral artery diseases before and after the acute event. In the present review, we will discuss the novel role of noncoding RNAs in modulating platelet function, highlighting the possible implications in activation and aggregation.
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Affiliation(s)
- Giovanni Cimmino
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
- Cardiology Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, Piazza Miraglia, 80138 Naples, Italy
| | - Stefano Conte
- Department of Translational Medical Sciences, Section of Lung Diseases, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
| | - Domenico Palumbo
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
| | - Simona Sperlongano
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
- Cardiology Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, Piazza Miraglia, 80138 Naples, Italy
| | - Michele Torella
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
| | - Paolo Golino
- Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, L. Bianchi Street, 80131 Naples, Italy
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De Servi S, Landi A, Savonitto S, Morici N, De Luca L, Montalto C, Crimi G, De Rosa R, De Luca G. Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field. J Clin Med 2023; 12:2082. [PMID: 36902869 PMCID: PMC10003933 DOI: 10.3390/jcm12052082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/23/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, 27100 Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland
| | | | - Nuccia Morici
- IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy
| | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, 00152 Roma, Italy
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
- Clinical and Interventional Cardiology, Istituto Clinico Sant’Ambrogio, Gruppo San Donato, 20122 Milan, Italy
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS, Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Roberta De Rosa
- University Hospital San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
- Goethe University Hospital Frankfurt, 60528 Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98039 Messina, Italy
- Division of Cardiology, Nuovo Galeazzi-Sant’Ambrogio Hospital, 20161 Milan, Italy
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23
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De Servi S, Landi A, Savonitto S, De Luca L, De Luca G, Morici N, Montalto C, Crimi G, Cattaneo M. Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice. J Cardiovasc Med (Hagerstown) 2023; 24:77-86. [PMID: 36583976 DOI: 10.2459/jcm.0000000000001399] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The assessment of bleeding and ischemic risk is a crucial step in establishing appropriate composition and duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary angioplasty. Evidence from recent randomized clinical trials led to some paradigm shifts in current guidelines recommendations. Options alternative to the standard 12-month DAPT duration include shorter periods of DAPT followed by single antiplatelet treatment with either aspirin or P2Y12 monotherapy, guided or unguided de-escalation DAPT, prolonged DAPT beyond the 12-month treatment period. Although DAPT composition and duration should be selected for each ACS patient on an individual basis weighing clinical and procedural variables, data from latest trials and meta-analyses may permit suggesting the most appropriate DAPT strategy according to the ischemic and bleeding risk assessed using validated tools and scores.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | | | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, Roma
| | - Giuseppe De Luca
- Clinical and Experimental Cardiology Unit, Azienda Ospedaliera-Universitaria di Sassari, University of Sassari, Sassari.,Clinical and Interventional Cardiology, Istituto Clinico Sant'Ambrogio, Gruppo San Donato
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, Milan
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genova
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24
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Heidari Moghadam R, Salehi N, Mahmoudi S, Shojaei L, Nasiri S, Siabani S, Janjani P, Rouzbahani M, Tadbiri H, Nalini M. Determinants of Left Ventricular Systolic Function One Year after Primary Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction in a Middle-Income Country. ARCHIVES OF IRANIAN MEDICINE 2023; 26:92-99. [PMID: 37543929 PMCID: PMC10685896 DOI: 10.34172/aim.2023.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/28/2022] [Indexed: 08/08/2023]
Abstract
BACKGROUND Little is known about the predictors of left ventricular ejection fraction (LVEF) -an important predictor of mortality- after primary percutaneous coronary intervention (PCI) in low- and middle-income countries. METHODS In a prospective cohort study at Imam Ali hospital, Kermanshah, Iran, we enrolled consecutive ST-elevation myocardial infarction (STEMI) patients treated with primary PCI (2016-2018) and followed them up to one year. LVEF levels were measured by echocardiography, at baseline and one-year follow-up. Determinants of preserved/improved LVEF were assessed using multi-variable logistic regression models. RESULTS Of 803 patients (mean age 58.53±11.7 years, 20.5% women), baseline LVEF levels of ≤35% were reported in 44%, 35- 50% in 40%, and ≥50% in 16% of patients. The mean ± SD of LVEF increased from 38.13%±9.2% at baseline to 41.49%±9.5% at follow-up. LVEF was preserved/improved in 629 (78.3%) patients. Adjusted ORs (95% CIs) for predictors of preserved/improved LVEF showed positive associations with creatinine clearance, 1.01 (1.00-1.02) and adherence to clopidogrel, 2.01 (1.33-3.02); and inverse associations with history of myocardial infarction (MI), 0.44 (0.25-0.78); creatine kinase MB (CK-MB), 0.997 (0.996- 0.999); door-balloon time (3rd vs. 1st tertile), 0.62 (0.39-0.98); number of diseased vessels (2 and 3 vs. 1: 0.63 (0.41-0.99) and 0.58 (0.36-0.93), respectively); and baseline LVEF (35-50% and ≥50% vs. ≤35%: 0.45 (0.28-0.71) and 0.19 (0.11-0.34), respectively). CONCLUSION Adherence to clopidogrel, short door-balloon time, high creatinine clearance, and lower baseline LVEF were associated with preserved/improved LVEF, while history of MI, high CK-MB, and multi-vessel disease were predictors of reduced LVEF. Long-term drug adherence should be considered for LVEF improvement in low- and middle-income countries.
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Affiliation(s)
- Reza Heidari Moghadam
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Nahid Salehi
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Susan Mahmoudi
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Lida Shojaei
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Sirus Nasiri
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Soraya Siabani
- Department of Health Education and Health Promotion, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Parisa Janjani
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Mohammad Rouzbahani
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Hooman Tadbiri
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
| | - Mahdi Nalini
- Cardiovascular Research Center, Health Institute, Kermanshah University of Medical Sciences, Imam Ali Hospital, Kermanshah, Iran
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Galli M, Franchi F, Rollini F, Ortega-Paz L, D'Amario D, De Caterina R, Mehran R, Gibson CM, Angiolillo DJ. Dual pathway inhibition in patients with atherosclerotic disease: pharmacodynamic considerations and clinical implications. Expert Rev Clin Pharmacol 2023; 16:27-38. [PMID: 36455906 DOI: 10.1080/17512433.2023.2154651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The persistence of elevated rates of ischemic recurrences despite the use of antiplatelet therapy among patients with atherosclerotic disease together with the understanding of the pivotal role of coagulation in the thrombo-inflammatory processes involved in the pathogenesis of atherosclerosis and its complications has fostered the development of treatments targeting both platelets and coagulation, a strategy known as dual-pathway inhibition (DPI). AREAS COVERED In this review we discuss the recent advancements in the understanding of the interplay between coagulation, platelets and inflammation involved in the pathophysiology of atherosclerosis and atherothrombosis, as the rationale for the implementation of a DPI strategy. We also discuss the available pharmacodynamic (PD) evidence and clinical implications with the use of DPI in patients with atherosclerotic disease. EXPERT OPINION The implementation of a DPI by adding the so-called 'vascular dose of rivaroxaban' (i.e. 2.5 mg bis in die), on top of antiplatelet therapy has consistently been associated with reduced levels of thrombin generation in PD studies and with reduced ischemic event rates at the cost of increased bleeding compared to antiplatelet therapy alone. Further research is warranted to best define patients in whom a DPI regimen has the best safety and efficacy profile.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Tanaka J, Koseki T, Sekido K, Kimata M, Ito Y, Yamada S. Occurrence of intraocular hemorrhages under monotherapy or combination therapy of antiplatelets and anticoagulants using the Japanese Adverse Drug Event Report database. JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES : A PUBLICATION OF THE CANADIAN SOCIETY FOR PHARMACEUTICAL SCIENCES, SOCIETE CANADIENNE DES SCIENCES PHARMACEUTIQUES 2023; 26:11263. [PMID: 37122387 PMCID: PMC10130193 DOI: 10.3389/jpps.2023.11263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023]
Abstract
Purpose: An intraocular hemorrhage is an adverse event that can lead to visual acuity impairment. Antithrombotic therapy with antiplatelet agents and anticoagulants may increase intraocular hemorrhage. However, since their frequency is low, studies on the risk of intraocular hemorrhage with these drugs, especially under combination therapy, are limited. This study aimed to investigate the occurrence of intraocular hemorrhages under monotherapy and combination therapy with antiplatelets and anticoagulants by analyzing a large pharmacovigilance database. Methods: Intraocular hemorrhage signals with oral antiplatelets and anticoagulants were evaluated by calculating reporting odds ratios and information components using the Japan Adverse Drug Reactions Report database from April 2004 to March 2022. In addition, differences in signals between younger and elderly patients, affecting factors, and time-to-onset from initial antiplatelet and anticoagulant treatments were analyzed. Results: Aspirin, clopidogrel, warfarin, apixaban, and rivaroxaban, but not ticagrelor, ticlopidine, prasugrel, dabigatran, and edoxaban showed intraocular hemorrhage signals under monotherapy. In combination therapy, dual therapy (aspirin + P2Y12 inhibitors, warfarin, direct oral anticoagulants, and P2Y12 inhibitors + warfarin) and triple therapy (aspirin + P2Y12 inhibitors + warfarin) resulted in intraocular hemorrhage signals. Intraocular hemorrhage signals were observed in younger patients receiving monotherapy with aspirin and in elderly patients receiving monotherapy and combination therapy with warfarin. Affecting factors were diabetes mellitus in patients with prasugrel, use of medications for intravitreal injections, and posterior sub-Tenon injections with some antiplatelets and anticoagulants. The median period of intraocular hemorrhage occurrence after starting monotherapy with aspirin, clopidogrel, warfarin, or rivaroxaban was within 90 days. Conclusion: In addition to monotherapy with several antiplatelets and anticoagulants, combination therapy using aspirin, P2Y12 inhibitors, and warfarin has the potential risk of intraocular hemorrhage. Particular attention should be paid to the occurrence of intraocular hemorrhages in younger patients taking aspirin, in elderly patients taking warfarin, and within the first 90 days of antiplatelet and anticoagulant use.
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Affiliation(s)
- Junko Tanaka
- Department of Pharmacotherapeutics and Informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Takenao Koseki
- Department of Pharmacotherapeutics and Informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- *Correspondence: Takenao Koseki,
| | - Kohsuke Sekido
- Department of Ophthalmology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Masashi Kimata
- Department of Ophthalmology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yasuki Ito
- Department of Ophthalmology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Shigeki Yamada
- Department of Pharmacotherapeutics and Informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Association of serum complement C1q with cardiovascular outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention. J Geriatr Cardiol 2022; 19:949-959. [PMID: 36632200 PMCID: PMC9807401 DOI: 10.11909/j.issn.1671-5411.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To determine the association of serum complement C1q levels with cardiovascular outcomes among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), and evaluate the value of C1q modified by high-sensitivity C-reactive protein (hs-CRP) levels as an independent predictor. METHODS As a single-center prospective observational study, we analyzed 1701 patients who had received primary or elective PCI for ACS at Beijing Anzhen Hospital, Capital Medical University, Beijing, China between June 1, 2016 and November 30, 2017. The associations of C1q modified by hs-CRP with major adverse cardiovascular events (MACE) were determined in survival analysis. RESULTS Patients with the lowest C1q tertile had the highest cumulative risk of MACE (log-rank P = 0.007). In fully adjusted Cox regression models, stratifying the total population according to hs-CRP dichotomy, C1q was significantly associated with MACE in patients with hs-CRP levels less than 2 mg/L but not in those with 2 mg/L or more (P interaction = 0.02). In patients with hs-CRP levels less than 2 mg/L, with the lowest C1q tertile as reference, the risk of MACE was reduced by 40.0% in the middle C1q tertile [hazard ratio (HR) = 0.600, 95% CI: 0.423-0.852, P = 0.004] and by 43.9% in the highest C1q tertile (HR = 0.561, 95% CI: 0.375-0.840, P = 0.005). CONCLUSIONS Serum complement C1q is significantly associated with cardiovascular outcomes in patients with ACS undergoing PCI, only when hs-CRP levels are less than 2 mg/L. This finding implicates the usefulness of C1q for the risk stratification in ACS patients with reduced systemic inflammation.
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Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
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Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Choo EH, Choi IJ, Lim S, Moon D, Kim CJ, Park MW, Kim MC, Hwang BH, Lee KY, Seok Choi Y, Kim HY, Yoo KD, Jeon DS, Ahn Y, Chang K. Prognosis and the Effect of De-Escalation of Antiplatelet Therapy After Nuisance Bleeding in Patients With Myocardial Infarction. Circ Cardiovasc Interv 2022; 15:e012157. [PMID: 36382599 DOI: 10.1161/circinterventions.122.012157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Data regarding prognosis and management after nuisance bleeding (NB) is limited. The purpose was to examine the prognostic significance of NB in patients receiving potent dual antiplatelet treatment (DAPT) after acute myocardial infarction and the impact of de-escalation of DAPT on clinical outcomes thereafter. METHODS From the TALOS-AMI trial (Ticagrelor Versus Clopidogrel in Stabilized Patients With Acute Myocardial Infarction)' 2583 patients were used to investigate the clinical impact of NB (defined as Bleeding Academic Research Consortium [BARC] 1 bleeding) during 1-month treatment with ticagrelor-based DAPT after acute myocardial infarction. We assessed the associations between NB within 1 month and BARC 2, 3, or 5 bleeding and major adverse cardiovascular event (a composite of cardiovascular death, myocardial infarction, stroke) from 1 to 12 months. We also evaluated the effect of de-escalation to clopidogrel in patients with or without NB. RESULTS NB occurred in 416 patients (16.7%) after 1 month of ticagrelor-based DAPT. At 1 year, NB was not associated with increase in BARC 2, 3, or 5 bleeding (hazard ratio [HR]' 1.29 [95% CI' 0.7-2.14]) and major adverse cardiovascular event (HR' 1.72 [95% CI' 0.87-3.39]). However, patients with NB had an increased risk of BARC 2, 3, or 5 bleeding at 6 months (HR, 1.94 [95% CI, 1.08-3.48]; P=0.026), which diminished over the next 6 months. De-escalation from ticagrelor to clopidogrel reduced the incidence of BARC 2, 3, or 5 bleeding compared with ticagrelor plus aspirin in NB (HR' 0.31 [95% CI' 0.10-0.92]) and non-NB patients (HR' 0.58 [95% CI' 0.37-0.90]) without heterogeneity (P interaction=0.291). There was no increase in major adverse cardiovascular event after DAPT de-escalation, irrespective of NB. CONCLUSIONS NB was frequent in patients with acute myocardial infarction on 1-month ticagrelor-based DAPT and was associated with an early increase of bleeding. DAPT de-escalation after NB may reduce bleeding without increasing ischemic events. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02018055.
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Affiliation(s)
- Eun Ho Choo
- Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea (E.H.C., B.-H.H, K.Y.L., Y.S.C., K.C.)
| | - Ik Jun Choi
- Division of Cardiology, Incheon St. Mary's Hospital, The Catholic University of Korea (I.J.C., D.S.J.)
| | - Sungmin Lim
- Division of Cardiology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea (S.L., J.K.)
| | - Donggyu Moon
- Division of Cardiology, St. Vincent's Hospital, The Catholic University of Korea, Suwon (D.M., K.D.Y.)
| | - Chan Joon Kim
- Division of Cardiology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea (S.L., J.K.)
| | - Mahn-Won Park
- Division of Cardiology, Daejeon St. Mary's Hospital, The Catholic University of Korea (M.-W.P.)
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea (M.C.K., Y.A.)
| | - Byung-Hee Hwang
- Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea (E.H.C., B.-H.H, K.Y.L., Y.S.C., K.C.)
| | - Kwan Yong Lee
- Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea (E.H.C., B.-H.H, K.Y.L., Y.S.C., K.C.)
| | - Yun Seok Choi
- Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea (E.H.C., B.-H.H, K.Y.L., Y.S.C., K.C.).,Division of Cardiology, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul (Y.S.C.)
| | - Hee-Yeol Kim
- Division of Cardiology, Bucheon St. Mary's Hospital, The Catholic University of Korea (H.-Y.K)
| | - Ki-Dong Yoo
- Division of Cardiology, St. Vincent's Hospital, The Catholic University of Korea, Suwon (D.M., K.D.Y.)
| | - Doo Soo Jeon
- Division of Cardiology, Incheon St. Mary's Hospital, The Catholic University of Korea (I.J.C., D.S.J.)
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea (M.C.K., Y.A.)
| | - Kiyuk Chang
- Division of Cardiology, Seoul St. Mary's Hospital, The Catholic University of Korea (E.H.C., B.-H.H, K.Y.L., Y.S.C., K.C.)
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The Value of Rivaroxaban Combined with Ticagrelor in Antithrombotic Therapy after PCI in Patients with Nonvalvular Atrial Fibrillation with Acute Coronary Syndrome. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4807175. [PMID: 36387358 PMCID: PMC9649311 DOI: 10.1155/2022/4807175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 11/05/2022]
Abstract
Objective Based on a retrospective cohort study, to investigate the value of rivaroxaban combined with ticagrelor in antithrombotic therapy after PCI in patients with nonvalvular atrial fibrillation with acute coronary syndrome. Methods A total of 60 patients from January 2019 to May 2021 accepted therapy with antithrombotic therapy after PCI. The patients treated with ticagrelor were set as the control group, and those given rivaroxaban combined with ticagrelor were set as the research group. The curative effect, myocardial level, TIMI blood flow grade, platelet aggregation rate, and the incidence of cardiovascular events were taken from the comparisons. Results The research group's therapeutic impact was superior to the control group's therapeutic impact, and the value was higher. After treatment, the myocardial levels of the two groups decreased, and the levels of troponin I, creatine kinase isoenzyme, and hypersensitive C-reactive protein in the research group were greatly less than those in the control group, and the difference was statistically significant (P < 0.05). After operation, the TIMI blood flow classification in the experimental group was better than that in the control group, and the difference was statistically significant (P < 0.05). The experimental group's platelet aggregation incidence was considerably lower than the control group's platelet aggregation incidence at 0.5 and 2 hours following surgery, and the difference was statistically significant (P < 0.05). The incidence of acute myocardial infarction, cardiogenic death, and intractable angina pectoris in the research group was significantly lower than that in the control group. Conclusion Rivaroxaban combined with ticagrelor in the treatment of nonvalvular atrial fibrillation with acute coronary syndrome after percutaneous coronary intervention; the TIMI blood flow grade is better than ticagrelor, which is of great significance to reduce mortality and has high safety in clinical application.
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Palmerini T, Bruno AG, Gasparini M, Rizzello G, Kim HS, Kang J, Park KW, Hahn JY, Song YB, Gwon HC, Choo EH, Park MW, Kim CJ, Chang K, Cuisset T, Taglieri N, Kim BK, Jang Y, Nardi E, Saia F, Orzalkiewicz M, Chietera F, Ghetti G, Galiè N, Stone GW. Reduced Mortality With Antiplatelet Therapy Deescalation After Percutaneous Coronary Intervention in Acute Coronary Syndromes: A Meta-Analysis. Circ Cardiovasc Interv 2022; 15:906-914. [PMID: 36378738 DOI: 10.1161/circinterventions.122.012245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antiplatelet therapy deescalation has been suggested as an alternative to standard treatment with potent dual antiplatelet therapy (DAPT) for 1 year in low bleeding risk patients with acute coronary syndromes undergoing percutaneous coronary intervention to mitigate the increased risk of bleeding. Whether this strategy preserves the ischemic and survival benefits of potent DAPT is uncertain. METHODS We performed a pairwise meta-analysis in patients with acute coronary syndrome undergoing percutaneous coronary intervention treated with either 1-year standard potent DAPT versus deescalation therapy (potent DAPT for 1-3 months followed by either reduced potency DAPT or ticagrelor monotherapy for up to 1 year). Randomized trials comparing standard DAPT versus deescalation therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary end point was 1-year all-cause mortality. RESULTS The meta-analysis included 6 trials in which 20 837 patients were randomized to potent DAPT for 1 to 3 months followed by deescalation therapy for up to 1 year (n=10 392) or standard potent DAPT for 1 year (n=10 445). Deescalation therapy was associated with lower 1-year rates of all-cause mortality compared with standard therapy (odds ratio, 0.75 [95% CI, 0.59-0.95]; P=0.02). Deescalation therapy was also associated with lower rates of major bleeding (odds ratio, 0.59 [95% CI, 0.48-0.72]; P<0.0001), with no significant difference in major adverse cardiac events (major adverse cardiovascular events; odds ratio, 0.89 [95% CI, 0.77-1.04]; P=0.14). CONCLUSIONS In low bleeding risk patients with acute coronary syndrome undergoing percutaneous coronary intervention, compared with 1-year of potent DAPT, antiplatelet therapy deescalation therapy after 1 to 3 months was associated with decreased mortality and major bleeding with similar rates of major adverse cardiovascular events.
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Affiliation(s)
- Tullio Palmerini
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Antonio Giulio Bruno
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Mauro Gasparini
- Dipartimento di Scienze Matematiche, Politecnico di Torino, Italy (M.G., G.R.)
| | - Giulia Rizzello
- Dipartimento di Scienze Matematiche, Politecnico di Torino, Italy (M.G., G.R.)
| | - Hyo-Soo Kim
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea (H.-S.K., J.K., K.-W.P.)
| | - Jeehoon Kang
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea (H.-S.K., J.K., K.-W.P.)
| | - Kyung-Woo Park
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea (H.-S.K., J.K., K.-W.P.)
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.-Y.H., Y.B.S., H.-C.G.)
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.-Y.H., Y.B.S., H.-C.G.)
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (J.-Y.H., Y.B.S., H.-C.G.)
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of South Korea (E.H.C., K.C.)
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, The Catholic University of South Korea (M.-W.P.)
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of South Korea (C.J.K.)
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of South Korea (E.H.C., K.C.)
| | - Thomas Cuisset
- Department of Cardiology, CHU Timone, Marseille, France (T.C.)
| | - Nevio Taglieri
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Byeong-Keuk Kim
- Division of Cardiology, Yonsei University Severance Cardiovascular Hospital, Seoul, South Korea (B.-K.K.)
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea (Y.J.)
| | - Elena Nardi
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Francesco Saia
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Matheusz Orzalkiewicz
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Francesco Chietera
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Gabriele Ghetti
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Nazzareno Galiè
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.)
| | - Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.)
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Choi KH, Park YH, Song YB, Park TK, Lee JM, Yang JH, Choi JH, Choi SH, Oh JH, Chun WJ, Jang WJ, Im ES, Jeong JO, Cho BR, Oh SK, Yun KH, Cho DK, Lee JY, Koh YY, Bae JW, Choi JW, Lee WS, Yoon HJ, Lee SU, Cho JH, Choi WG, Rha SW, Gwon HC, Hahn JY. Long-term Effects of P2Y12 Inhibitor Monotherapy After Percutaneous Coronary Intervention: 3-Year Follow-up of the SMART-CHOICE Randomized Clinical Trial. JAMA Cardiol 2022; 7:1100-1108. [PMID: 36169938 PMCID: PMC9520445 DOI: 10.1001/jamacardio.2022.3203] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
Importance Although P2Y12 inhibitor monotherapy after a minimum period of dual antiplatelet therapy (DAPT) is a well-known way to reduce the risk of bleeding after percutaneous coronary intervention (PCI), data comparing long-term clinical outcomes between P2Y12 inhibitor monotherapy and extended DAPT in patients undergoing PCI have been unavailable. Objective To identify the long-term safety and efficacy of P2Y12 inhibitor monotherapy following 3 months of DAPT after PCI. Design, Setting, and Participants The Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy and Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) trial was an open-label, noninferiority, randomized clinical trial, enrolling patients who underwent PCI with drug-eluting stent at 33 hospitals in Korea from March 2014 through July 2017. Clinical follow-up was extended to 3 years and completed in August 2020. Interventions Patients were randomly assigned to either P2Y12 inhibitor monotherapy after 3 months of DAPT or DAPT for 12 months or longer. Main Outcomes and Measures The primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 3 years. The secondary end points included the components of the primary end point, bleeding (defined as Bleeding Academic Research Consortium [BARC] types 2-5), and major bleeding (BARC types 3-5). Results In total, 2993 patients were randomly assigned to receive P2Y12 inhibitor monotherapy after 3 months of DAPT (1495 patients [50%]; mean [SD] age, 64.6 [10.7] years; 1087 [72.7%] male) or prolonged DAPT (1498 patients [50%]; mean [SD] age, 64.6 [10.7] years; 1111 [74.2%] male) after PCI. At 3 years, the primary end point occurred in 87 individuals (6.3%) in the P2Y12 inhibitor monotherapy group and 83 (6.1%) in the prolonged DAPT group (hazard ratio [HR], 1.06 [95% CI, 0.79-1.44]; P = .69). P2Y12 inhibitor monotherapy significantly reduced the risk of bleeding (BARC types 2-5: 112 [3.2%] vs 44 [8.2%]; HR, 0.39 [95% CI, 0.28-0.55]; P < .001) and major bleeding (BARC types 3-5; 17 [1.2%] vs 31 [2.4%]; HR, 0.56 [95% CI, 0.31-0.99]; P = .048), compared with prolonged DAPT. The landmark analyses between 3 months and 3 years and per-protocol analyses showed consistent results. Conclusions and Relevance Among patients who underwent PCI and completed 3-month DAPT, P2Y12 inhibitor monotherapy was associated with a lower risk of clinically relevant major bleeding than prolonged DAPT. Although the 3-year risk of ischemic cardiovascular events was comparable between the 2 groups, this result should be interpreted with caution owing to the limited number of events and sample size. Trial Registration ClinicalTrials.gov Identifier: NCT02079194.
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Affiliation(s)
- Ki Hong Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Hwan Park
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Hyeon Oh
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Woo Jung Chun
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Woo Jin Jang
- Department of Cardiology, Ewha Woman's University Seoul Hospital, Ewha Woman's University School of Medicine, Seoul, Korea
| | - Eul-Soon Im
- Division of Cardiology, Dongsuwon General Hospital, Suwon, Korea
| | - Jin-Ok Jeong
- Chungnam National University Hospital, Daejeon, Korea
| | - Byung Ryul Cho
- Division of Cardiology, Kangwon National University Hospital, Chuncheon, Korea
| | - Seok Kyu Oh
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
| | - Kyeong Ho Yun
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
| | - Deok-Kyu Cho
- Division of Cardiology, Department of Internal Medicine, Yongin Severance Hospital, Yongin, Korea
| | - Jong-Young Lee
- Division of Cardiology, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Youp Koh
- Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, College of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | | | | | - Hyuck Jun Yoon
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | | | | | | | | | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Laborante R, Borovac JA, Galli M, Rodolico D, Ciliberti G, Restivo A, Cappannoli L, Arcudi A, Vergallo R, Zito A, Princi G, Leone AM, Aurigemma C, Romagnoli E, Montone RA, Burzotta F, Trani C, D’Amario D. Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome? Front Cardiovasc Med 2022; 9:1009475. [PMID: 36386309 PMCID: PMC9659635 DOI: 10.3389/fcvm.2022.1009475] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/14/2022] [Indexed: 08/11/2023] Open
Abstract
The incidence and clinical presentation of ischemic heart disease (IHD), as well as thrombotic and bleeding risks, appear to differ between genders. Compared with men, women feature an increased thrombotic risk, probably related to an increased platelet reactivity, higher level of coagulation factors, and sex-associated unique cardiovascular risk factors, such as pregnancy-related (i.e., pre-eclampsia and gestational diabetes), gynecological disorders (i.e., polycystic ovary syndrome, early menopause) and autoimmune or systemic inflammatory diseases. At the same time, women are also at increased risk of bleeding, due to inappropriate dosing of antithrombotic agents, smaller blood vessels, lower body weight and comorbidities, such as diabetes and chronic kidney disease. Pharmacological strategies focused on the personalization of antithrombotic treatment may, therefore, be particularly appealing in women in light of their higher bleeding and ischemic risks. Paradoxically, although women represent a large proportion of cardiovascular patients in our practice, adequate high-quality clinical trial data on women remain scarce and inadequate to guide decision-making processes. As a result, IHD in women tends to be understudied, underdiagnosed and undertreated, a phenomenon known as a "Yentl syndrome." It is, therefore, compelling for the scientific community to embark on dedicated clinical trials to address underrepresentation of women and to acquire evidence-based knowledge in the personalization of antithrombotic therapy in women.
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Affiliation(s)
- Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Josip Andjelo Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Cappannoli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Arcudi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Zito
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D’Amario
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Escalation and De-Escalation of Antiplatelet Therapy after Acute Coronary Syndrome or PCI: Available Evidence and Implications for Practice. J Clin Med 2022; 11:jcm11216246. [PMID: 36362474 PMCID: PMC9654330 DOI: 10.3390/jcm11216246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard for the antithrombotic management of patients with an acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Implementation of intensified or prolonged DAPT regimens has proven to lower the risk of ischemic events but at the expense of increased bleeding. Importantly, bleeding is a predictor of poor prognosis. Risk stratification and selection of tailored antiplatelet strategies to maximize the net clinical benefit in individual patients with ACS or undergoing PCI is therefore potentially beneficial. Recently, novel approaches including DAPT de-escalation or escalation have been proposed as possible alternatives to standard DAPT. These strategies, which are generally based on patient's risk profile, genetics, and/or platelet function have been proposed to offer more tailored treatments in patients with ACS or PCI, with the ultimate goal of providing adequate ischemic protection while mitigating the risk of bleeding. This review summarizes the available evidence on DAPT de-escalation or escalation (both guided and unguided) and discusses the practical implications of these strategies in the contemporary management of patients with ACS and/or undergoing PCI.
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Kaur G, Chand S, Rai D, Baibhav B, Blankstein R, Mukherjee D, Levy P, Gulati M. Contemporary Risk Stratification of Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chest pain is one of the most common presenting concerns of patients seeking care in the emergency department, and the underlying etiology can range from acute coronary syndrome to various other non-cardiac causes. Initial evaluation should focus on characterizing symptoms and identifying risk factors, but further risk stratification using clinical decision pathways and biomarkers (cardiac troponin) is essential. The 2021 American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain represent the first ever guidelines for the evaluation of patients with acute chest pain. The contemporary risk stratification methods described in these guidelines allow for the identification of patient subgroups: patients who do not require further testing, patients who should proceed directly to the cath lab, and patients who will benefit from further anatomic or functional testing. In this review, we describe contemporary risk stratification methods for acute coronary syndrome and summarize the recommendations put forth by the guidelines.
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Affiliation(s)
- Gurleen Kaur
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Swati Chand
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Bipul Baibhav
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center at El Paso, El Paso, TX
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
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Lahu S, Presch A, Ndrepepa G, Menichelli M, Valina C, Hemetsberger R, Witzenbichler B, Bernlochner I, Joner M, Xhepa E, Hapfelmeier A, Kufner S, Rifatov N, Sager HB, Mayer K, Kessler T, Laugwitz KL, Richardt G, Schunkert H, Neumann FJ, Sibbing D, Angiolillo DJ, Kastrati A, Cassese S. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndrome and High Bleeding Risk. Circ Cardiovasc Interv 2022; 15:e012204. [PMID: 36256695 DOI: 10.1161/circinterventions.122.012204] [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] [Indexed: 01/10/2023]
Abstract
BACKGROUND The relative efficacy and safety of more potent P2Y12 inhibitors in patients with acute coronary syndrome and high bleeding risk (HBR) undergoing percutaneous coronary intervention remains unclear. We aimed to study the treatment effect of ticagrelor and prasugrel in percutaneous coronary intervention patients presenting with acute coronary syndrome and HBR. METHODS This post hoc analysis of the ISAR-REACT 5 trial (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5) included patients with acute coronary syndrome undergoing percutaneous coronary intervention, randomized to ticagrelor or prasugrel, in whom HBR was defined as per Academic Research Consortium criteria. The primary (efficacy) end point was the composite of all-cause death, myocardial infarction, or stroke. The secondary (safety) end point was Bleeding Academic Research Consortium type 3 to 5 bleeding. Outcomes were assessed 12 months after randomization. RESULTS Out of the 3239 patients included in this analysis, 486 fulfilled the criteria for Academic Research Consortium-HBR definition (HBR group; ticagrelor, n=230 and prasugrel, n=256), while 2753 did not (non-HBR group; ticagrelor, n=1375 and prasugrel, n=1378). Compared with the non-HBR group, the HBR group had a higher risk for the primary (hazard ratio [HR]=3.57 [95% CI, 2.79-4.57]; P<0.001) and secondary end point (HR=2.94 [2.17-3.99]; P<0.001). In the HBR group, the primary (HR=1.09 [0.73-1.62]) and secondary (HR=1.18 [0.67-2.08]) end points were not significantly different between patients assigned to ticagrelor and prasugrel. In the non-HBR group, the primary end point (HR=1.62 [1.19-2.20]) occurred more frequently in patients assigned to ticagrelor as compared to patients assigned to prasugrel, without difference in safety (HR=1.08 [0.74-1.58]). There was no significant treatment allocation-by-HBR status interaction with respect to the primary (P for interaction=0.12) or secondary (P for interaction=0.80) end points. CONCLUSIONS In patients with acute coronary syndrome undergoing percutaneous coronary intervention, HBR status increased both ischemic and bleeding risk without significant impact on the relative efficacy and safety of either ticagrelor or prasugrel. These results warrant confirmation in larger cohorts. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Antonia Presch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany (C.V., F.-J.N.)
| | - Rayyan Hemetsberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (R.H.)
| | | | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (I.B., K.-L.L.)
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute for AI and Informatics in Medicine, Germany (A.H.)
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Germany (A.H.)
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Nonglag Rifatov
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Hendrik B Sager
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Katharina Mayer
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Thorsten Kessler
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (I.B., K.-L.L.)
| | - Gert Richardt
- Heart Center Bad Segeberg, Segeberger Kliniken GmbH, Bad Segeberg, Germany (G.R.)
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany (C.V., F.-J.N.)
| | - Dirk Sibbing
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München (D.S.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
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Park DY, Wang P, An S, Grimshaw AA, Frampton J, Ohman EM, Rao SV, Nanna MG. Shortening the duration of dual antiplatelet therapy after percutaneous coronary intervention for acute coronary syndrome: A systematic review and meta-analysis. Am Heart J 2022; 251:101-114. [PMID: 35654162 PMCID: PMC10904033 DOI: 10.1016/j.ahj.2022.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The decision to shorten the duration of DAPT following PCI in patients with ACS remains controversial because of the concern for increased ischemic events. METHODS We performed a comprehensive literature search in seven databases to explore the efficacy of 1 to 3 months of DAPT in patients who underwent PCI for ACS. Randomized controlled trials that compared 1 to 3 months with 6 to 12 months of DAPT after PCI for ACS were identified. Integrated hazard ratio (HR) and 95% confidence interval (CI) were calculated by random effects model for each prespecified outcome of interest. Meta-regression analyses were performed to examine the association of outcomes with select patient characteristics. RESULTS A total of 9 randomized controlled trials consisting of 25,907 patients were included. There was no difference in the hazard of NACE (HR 0.92, 95% CI 0.79-1.07) and MACE (HR 0.96, 95% CI 0.78-1.17) between 1 and 3 months of DAPT and 6 to 12 months of DAPT. However, implementing 1 to 3 months of DAPT was associated with lower hazard of both any bleeding (HR 0.55, 95% CI 0.46-0.66) and major bleeding (HR 0.47, 95% CI 0.36-0.62). Meta-regression revealed a nonsignificant but increasing trend of both NACE and MACE with greater proportion of left main and left anterior descending coronary artery lesions and greater proportion of STEMI included in the trials. CONCLUSION Our findings suggest that 1 to 3 months of DAPT has similar efficacy for preventing ischemic events with reduced bleeding risk compared with 6 to 12 months of DAPT.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL
| | - Peter Wang
- Department of Medicine, Yale New Haven Hospital, New Haven, CT.
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | | | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Sunil V Rao
- The Duke Clinical Research Institute, Durham NC
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
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Matsuura Y, Moribayashi K, Kaikita K. Optimal Antithrombotic Therapy in Patients Undergoing Percutaneous Coronary Intervention: A Focused Review on High Bleeding Risk. J Atheroscler Thromb 2022; 29:1409-1420. [PMID: 35934784 PMCID: PMC9529379 DOI: 10.5551/jat.rv17066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is a therapeutic cornerstone to prevent stent thrombosis following percutaneous coronary intervention (PCI) for coronary artery disease (CAD). However, the longer the DAPT duration, the higher the incidence of bleeding and mortality. Since the advent of second-generation drug-eluting stents (DES), the continuous evolution of DES has reduced the thrombotic risk and allowed for a shorter DAPT duration. On the other hand, concerns on the elevated risk of bleeding during antithrombotic therapy have been further raised due to the growing number of elderly CAD patients with multiple comorbidities. The consequent debate topic over post-PCI antithrombotic therapy has shifted from simply reducing thrombotic risk to safely minimizing bleeding risk. Due to the significant impact of bleeding on clinical outcomes, including prognosis, current guidelines on antithrombotic therapy for CAD prioritize stratification of patients at a high bleeding risk (HBR) as the top consideration in determining post-PCI antithrombotic therapy. Achieving optimal antithrombotic therapy for each patient undergoing PCI requires a better understanding of the clinical variables constituting the balance of bleeding and thrombotic risk. This review highlights relevant evidence required to optimize antithrombotic therapy for HBR patients undergoing PCI.
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Affiliation(s)
- Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki
| | - Kohei Moribayashi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 1). JACC. ASIA 2022; 2:395-411. [PMID: 36339361 PMCID: PMC9627863 DOI: 10.1016/j.jacasi.2022.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Bai N, Ma Y, Niu Y, Zhong PY, Shang YS, Wang ZL. Efficacy and Safety of De-escalation of Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: A Meta-Analysis of Randomized Clinical Trials. J Cardiovasc Pharmacol 2022; 80:226-235. [PMID: 35416803 DOI: 10.1097/fjc.0000000000001274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Considering that there is no definite conclusion on the efficacy and safety of switching from potent P2Y 12 inhibitors to clopidogrel, we conducted a systematic review and meta-analysis of patients with acute coronary syndromes undergoing percutaneous coronary intervention and compared the efficacy and safety of de-escalation or not of antiplatelet therapy. The relevant randomized controlled trials were included by searching several databases. Net adverse clinical events were identified as the composite end point, which was defined as a composite of cardiovascular death, myocardial infarction, revascularization, stroke, and bleeding at 12 months after acute coronary syndromes. The efficacy end points were cardiovascular death, myocardial infarction, revascularization, stroke, all-cause death, and stent thrombosis. Bleeding was designed as the safety end point. The risk ratio and 95% confidence intervals of end point events were calculated by the fixed-effects model. Six randomized controlled trials with 7627 patients met inclusion criteria. There were significant differences in the risk of net adverse clinical events (RR, 0.67, CI, 0.58-0.78, P < 0.00001) and bleeding end point (0.61, 0.52-0.71, P < 0.00001) between the 2 groups. However, there were no significant differences in the risk of all efficacy end points. In general, the strategy of de-escalation from prasugrel or ticagrelor to clopidogrel can reduce the incidence of net adverse clinical events and bleeding events in patients with ACS undergoing percutaneous coronary intervention.
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Affiliation(s)
- Nan Bai
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; and
| | - Ying Ma
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; and
| | - Ying Niu
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; and
| | - Peng-Yu Zhong
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; and
| | - Yao-Sheng Shang
- The First Clinical Medical College, Lanzhou University, Lanzhou, China; and
| | - Zhi-Lu Wang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
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Araiza-Garaygordobil D, Gopar-Nieto R, Sierra-Lara Martínez D, Belderrain-Morales N, Sarabia-Chao V, Alfaro-Ponce DL, Ontiveros-Mercado H, Mendoza-García S, Altamirano-Castillo A, Martinez-Amezcua P, Cabello-López A, Briseño-De la Cruz JL, Ruiz-Beltrán M, Martínez-Ríos MA, Piña-Reyna Y, Gonzalez-Pacheco H, Arias-Mendoza A. Dual Antiplatelet Therapy Versus Antiplatelet Monotherapy Plus Oral Anticoagulation in Patients with Acute Coronary Syndrome and Coronary Artery Ectasia: Design and Rationale of OVER-TIME Randomized Clinical Trial. High Blood Press Cardiovasc Prev 2022; 29:463-468. [PMID: 35904750 DOI: 10.1007/s40292-022-00535-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/18/2022] [Indexed: 10/16/2022] Open
Abstract
INTRODUCTION The optimal anti-thrombotic therapy to prevent recurrent ischemic events in patients with acute coronary syndrome and coronary artery ectasia (CAE) remains unclear. AIM To assess the efficacy and safety of antiplatelet plus anticoagulant therapy versus dual antiplatelet therapy in patients with acute coronary syndromes and coronary artery ectasia. METHODS OVER-TIME is an investigator initiated, exploratory, open label, single center, randomized clinical trial comparing dual antiplatelet therapy (acetyl-salicylic acid plus a P2Y12 inhibitor) with the combination of an antiplatelet monotherapy (a P2Y12 inhibitor) plus a low dose anticoagulant (rivaroxaban, 15mg oral dose) for the prevention of recurrent ischemic events among patients with CAE. We aim to enroll approximately 60 patients with CAE and acute coronary syndromes. After recruitment, patients are randomized to (a) standard of care (dual antiplatelet regimen) or (b) the combination of antiplatelet monotherapy and low dose anticoagulant. Patients will be followed for at least 12 months. The OVER-TIME study aims to assess the efficacy of the regimen in prevention of major cardiovascular events and its security in bleeding events in acute coronary syndromes among patients with CAE. Expected results and conclusions: OVER-TIME is the first randomized controlled trial to assess different antithrombotic strategies in patients with CAE and acute coronary syndrome, and its results will offer preliminary data for the prevention of major cardiovascular events and bleeding events in this group of patients. TRIAL REGISTRATION NUMBER NCT05233124 (ClinicalTrials.gov), date of registration: February 10, 2022.
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Affiliation(s)
- Diego Araiza-Garaygordobil
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico.
| | - Rodrigo Gopar-Nieto
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Daniel Sierra-Lara Martínez
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Nallely Belderrain-Morales
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Vianney Sarabia-Chao
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Diana Laura Alfaro-Ponce
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Heriberto Ontiveros-Mercado
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Salvador Mendoza-García
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Alfredo Altamirano-Castillo
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Pablo Martinez-Amezcua
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, USA
| | - Alejandro Cabello-López
- Occupational Health Research Unit, Centro Médico Nacional Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Jose Luis Briseño-De la Cruz
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Maximiliano Ruiz-Beltrán
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | | | - Yigal Piña-Reyna
- Interventional Cardiology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Hector Gonzalez-Pacheco
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
| | - Alexandra Arias-Mendoza
- Coronary Care Unit, National Institute of Cardiology "Ignacio Chávez", Juan Badiano 1, Belisario Dominguez Sección XVI, Tlalpan, 14030, Mexico City, Mexico
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Polymer–Metal Composite Healthcare Materials: From Nano to Device Scale. JOURNAL OF COMPOSITES SCIENCE 2022. [DOI: 10.3390/jcs6080218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Metals have been investigated as biomaterials for a wide range of medical applications. At nanoscale, some metals, such as gold nanoparticles, exhibit plasmonics, which have motivated researchers’ focus on biosensor development. At the device level, some metals, such as titanium, exhibit good physical properties, which could allow them to act as biomedical implants for physical support. Despite these attractive features, the non-specific delivery of metallic nanoparticles and poor tissue–device compatibility have greatly limited their performance. This review aims to illustrate the interplay between polymers and metals, and to highlight the pivotal role of polymer–metal composite/nanocomposite healthcare materials in different biomedical applications. Here, we revisit the recent plasmonic engineered platforms for biomolecules detection in cell-free samples and highlight updated nanocomposite design for (1) intracellular RNA detection, (2) photothermal therapy, and (3) nanomedicine for neurodegenerative diseases, as selected significant live cell–interactive biomedical applications. At the device scale, the rational design of polymer–metallic medical devices is of importance for dental and cardiovascular implantation to overcome the poor physical load transfer between tissues and devices, as well as implant compatibility under a dynamic fluidic environment, respectively. Finally, we conclude the treatment of these innovative polymer–metal biomedical composite designs and provide a future perspective on the aforementioned research areas.
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Barcelona R. Best Practices in Pharmacotherapy for Acute Coronary Syndromes. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Numerous advances have been made in the therapy of acute coronary syndromes. Despite these advances, acute coronary syndromes still cause significant morbidity and mortality. Decisions as to the best therapy vary depending on other patient factors, such as age, need for chronic anticoagulation, tolerability of medications, and the degree of myocardial damage. Recent evidence suggests that a shorter duration of therapy may be beneficial in decreasing bleeding events without compromising benefits of preventing ischemic complications. For those who have an indication for chronic anticoagulation, less intensive therapy may also be beneficial, again without increasing ischemic complications. Data regarding agents that inhibit the renin–angiotensin–aldosterone system are available and these data are reviewed. Knowledge of the pharmacology, potency, and pharmacokinetics of drugs, as well as adverse drug events, may direct clinicians in choosing the optimal pharmacotherapy strategy for their patients.
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Affiliation(s)
- Robert Barcelona
- Cardiac Intensive Care Unit, University Hospitals Cleveland Medical Center, Cleveland, OH
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Cho MS, Kang DY, Oh YS, Lee CH, Choi EK, Lee JH, Kwon CH, Park GM, Park HW, Park KH, Park KM, Hwang J, Yoo KD, Cho YR, Kim YR, Hwang KW, Jin ES, Kim PJ, Kim KH, Park DW, Nam GB. Edoxaban-based long-term antithrombotic therapy in patients with atrial fibrillation and stable coronary disease: Rationale and design of the randomized EPIC-CAD trial. Am Heart J 2022; 247:123-131. [PMID: 35149036 DOI: 10.1016/j.ahj.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD. DESIGN The EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA2DS2-VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization. RESULTS As of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023. CONCLUSIONS EPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD.
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Farmakis IT, Zafeiropoulos S, Doundoulakis I, Pagiantza A, Karagiannidis E, Moysidis DV, Stalikas N, Kassimis G, Michalis LK, Karvounis H, Giannakoulas G. Comparative efficacy and safety of oral P2Y 12 inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis. Open Heart 2022; 9:openhrt-2021-001937. [PMID: 35428703 PMCID: PMC9014125 DOI: 10.1136/openhrt-2021-001937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/31/2022] [Indexed: 11/20/2022] Open
Abstract
Background Currently, potent P2Y12 inhibition with the use of prasugrel or ticagrelor is the mainstay of treatment after an acute coronary syndrome (ACS). The 2020 European Society of Cardiology (ESC) Guidelines recommend the use of prasugrel over ticagrelor in patients with non-ST-elevation ACS (NSTE-ACS) intended to receive invasive management (class IIa recommendation), however there are contradictory views regarding this recommendation. Aim To compare oral P2Y12 inhibitors in NSTE-ACS in terms of efficacy and safety with a focus on patients intended to proceed to invasive management. Methods We systematically searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) in patients with NSTE-ACS. Efficacy outcomes included the major adverse cardiovascular events outcome and safety outcomes included minor and major bleedings. We performed a frequentist network meta-analysis. Results Nine studies (n=35 441 patients) were included in the systematic review. There was no difference between prasugrel and ticagrelor in the composite cardiovascular end point (prasugrel vs ticagrelor HR=0.80, 95% CI=0.61 to 1.06) in all patients with NSTE-ACS. In patients intended to receive invasive management, prasugrel resulted in a reduction of the composite cardiovascular end point both versus clopidogrel (HR=0.76, 95% CI=0.61 to 0.95) and ticagrelor (HR=0.74, 95% CI=0.56 to 0.98). Inconsistency was moderate and non-significant (I2=27%, total Q p=0.2). Prasugrel ranked as the most efficient treatment in the composite cardiovascular efficacy outcome, all-cause death, myocardial infarction and definite stent thrombosis, while clopidogrel ranked as safest in the bleeding outcomes. Conclusion In patients with NSTE-ACS intended to receive invasive management, an antiplatelet strategy based on prasugrel is more efficient than a similar strategy based on ticagrelor on a moderate level of evidence. This analysis supports the current recommendations by the ESC guidelines.
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Affiliation(s)
- Ioannis T Farmakis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Ioannis Doundoulakis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Areti Pagiantza
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Stalikas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lampros K Michalis
- Second Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Haralambos Karvounis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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MacDougall C, Canonica T, Keh C, P. Phan BA, Louie J. Systematic review of drug–drug interactions between rifamycins and anticoagulant and antiplatelet agents and considerations for management. Pharmacotherapy 2022; 42:343-361. [DOI: 10.1002/phar.2672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Conan MacDougall
- Department of Clinical Pharmacy University of California San Francisco School of Pharmacy San Francisco California USA
| | - Theora Canonica
- Department of Clinical Pharmacy San Francisco Veterans' Affairs Medical Center San Francisco California USA
| | - Chris Keh
- Division of Infectious Disease University of California, San Francisco San Francisco California USA
| | - Binh An P. Phan
- Division of Cardiology San Francisco General Hospital University of California, San Francisco San Francisco California USA
| | - Janice Louie
- Division of Infectious Diseases San Francisco Department of Public Health Tuberculosis Clinic University of California, San Francisco San Francisco California USA
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Watanabe H, Morimoto T, Natsuaki M, Yamamoto K, Obayashi Y, Ogita M, Suwa S, Isawa T, Domei T, Yamaji K, Tatsushima S, Watanabe H, Ohya M, Tokuyama H, Tada T, Sakamoto H, Mori H, Suzuki H, Nishikura T, Wakabayashi K, Hibi K, Abe M, Kawai K, Nakao K, Ando K, Tanabe K, Ikari Y, Morino Y, Kadota K, Furukawa Y, Nakagawa Y, Kimura T. Comparison of Clopidogrel Monotherapy After 1 to 2 Months of Dual Antiplatelet Therapy With 12 Months of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndrome: The STOPDAPT-2 ACS Randomized Clinical Trial. JAMA Cardiol 2022; 7:407-417. [PMID: 35234821 PMCID: PMC8892373 DOI: 10.1001/jamacardio.2021.5244] [Citation(s) in RCA: 120] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Clopidogrel monotherapy after short dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) has not yet been fully investigated in patients with acute coronary syndrome (ACS). OBJECTIVE To test the hypothesis of noninferiority of 1 to 2 months of DAPT compared with 12 months of DAPT for a composite end point of cardiovascular and bleeding events in patients with ACS. DESIGN, SETTING, AND PARTICIPANTS This multicenter, open-label, randomized clinical trial enrolled 4169 patients with ACS who underwent successful PCI using cobalt-chromium everolimus-eluting stents at 96 centers in Japan from December 2015 through June 2020. These data were analyzed from June to July 2021. INTERVENTIONS Patients were randomized either to 1 to 2 months of DAPT followed by clopidogrel monotherapy (n = 2078) or to 12 months of DAPT with aspirin and clopidogrel (n = 2091). MAIN OUTCOMES AND MEASURES The primary end point was a composite of cardiovascular (cardiovascular death, myocardial infarction [MI], any stroke, or definite stent thrombosis) or bleeding (Thrombolysis in MI major or minor bleeding) events at 12 months, with a noninferiority margin of 50% on the hazard ratio (HR) scale. The major secondary end points were cardiovascular and bleeding components of the primary end point. RESULTS Among 4169 randomized patients, 33 withdrew consent. Of the 4136 included patients, the mean (SD) age was 66.8 (11.9) years, and 856 (21%) were women, 2324 (56%) had ST-segment elevation MI, and 826 (20%) had non-ST-segment elevation MI. A total of 4107 patients (99.3%) completed the 1-year follow-up in June 2021. One to 2 months of DAPT was not noninferior to 12 months of DAPT for the primary end point, which occurred in 65 of 2058 patients (3.2%) in the 1- to 2-month DAPT group and in 58 of 2057 patients (2.8%) in the 12-month DAPT group (absolute difference, 0.37% [95% CI, -0.68% to 1.42%]; HR, 1.14 [95% CI, 0.80-1.62]; P for noninferiority = .06). The major secondary cardiovascular end point occurred in 56 patients (2.8%) in the 1- to 2-month DAPT group and in 38 patients (1.9%) in the 12-month DAPT group (absolute difference, 0.90% [95% CI, -0.02% to 1.82%]; HR, 1.50 [95% CI, 0.99-2.26]). The major secondary bleeding end point occurred in 11 patients (0.5%) in the 1- to 2-month DAPT group and 24 patients (1.2%) in the 12-month DAPT group (absolute difference, -0.63% [95% CI, -1.20% to -0.06%]; HR, 0.46 [95% CI, 0.23-0.94]). CONCLUSIONS AND RELEVANCE In patients with ACS with successful PCI, clopidogrel monotherapy after 1 to 2 months of DAPT failed to attest noninferiority to standard 12 months of DAPT for the net clinical benefit with a numerical increase in cardiovascular events despite reduction in bleeding events. The directionally different efficacy and safety outcomes indicate the need for further clinical trials. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT02619760 and NCT03462498.
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Affiliation(s)
- Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Ko Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Kyohei Yamaji
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Shojiro Tatsushima
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hiroki Watanabe
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hideo Tokuyama
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | | | | | | | | | - Kiyoshi Hibi
- Department of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University Hospital, Isehara, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Morioka, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Huang SW, Chen PW, Feng WH, Hsieh IC, Ho MY, Cheng CW, Yeh HI, Chen CP, Huang WC, Fang CC, Lin HW, Lin SH, Tsai CF, Su CH, Li YH. Impact of the Dual Antiplatelet Therapy Score on Clinical Outcomes in Acute Coronary Syndrome Patients Receiving P2Y12 Inhibitor Monotherapy. Front Cardiovasc Med 2022; 8:772820. [PMID: 35284499 PMCID: PMC8907151 DOI: 10.3389/fcvm.2021.772820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/27/2021] [Indexed: 12/11/2022] Open
Abstract
Background Dual antiplatelet therapy (DAPT) score is used to stratify ischemic and bleeding risk for antiplatelet therapy after percutaneous coronary intervention (PCI). This study assessed the association between the DAPT score and clinical outcomes in acute coronary syndrome (ACS) patients who were treated with P2Y12 inhibitor monotherapy. Methods A total of 498 ACS patients, with early aspirin discontinuation for various reasons and who received P2Y12 inhibitor monotherapy after PCI, were enrolled during the period from January 1, 2014 to December 31, 2018. The efficacy and safety between those with low (<2) and high (≥2) DAPT scores were compared during a 12-month follow-up after PCI. Inverse probability of treatment weighting was used to balance the covariates between the two groups. The primary endpoint was a composite outcome of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months. The safety endpoint was major bleeding, defined as Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding. Results The primary composite endpoint occurred in 11.56 and 14.38% of the low and high DAPT score groups, respectively. Although there was no significant difference in the primary composite endpoint between the two groups in the multivariate Cox proportional hazards models, the risk of recurrent ACS or unplanned revascularization was significantly higher in the high DAPT score group (adjusted hazard ratio [HR]: 1.900, 95% confidence interval [CI]: 1.095-3.295). The safety outcome for BARC 3 or 5 bleeding was similar between the two groups. Conclusions Our results indicate that ACS patients receiving P2Y12 monotherapy with high DAPT score had an increased risk of recurrent ACS or unplanned revascularization.
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Affiliation(s)
- Sheng-Wei Huang
- School of Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, Taichung, Taiwan
| | - Po-Wei Chen
- College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Han Feng
- Kaohsiung Municipal Ta-Tung Hospital and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Chang Hsieh
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Yun Ho
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | | | - Hung-I Yeh
- Mackay Memorial Hospital, Taipei, Taiwan
| | | | - Wei-Chun Huang
- Kaohsiung Veterans General Hospital, Fooyin University, Kaohsiung and National Yang Ming University, Taipei, Taiwan
| | | | - Hui-Wen Lin
- College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Hsiang Lin
- College of Medicine, Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Biostatistics Consulting Center, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Feng Tsai
- School of Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Hung Su
- School of Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, Taichung, Taiwan
| | - Yi-Heng Li
- College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
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Espinola-Klein C. When and How to Combine Antiplatelet and Anticoagulant Drugs? Hamostaseologie 2022; 42:73-79. [PMID: 35196733 DOI: 10.1055/a-1724-4922] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Antiplatelet and anticoagulant drugs work at different places in the coagulation system. Antiplatelet drugs are usually indicated in patients with atherosclerosis. Anticoagulant drugs are mostly used in patients with atrial fibrillation, venous thromboembolism, or technical heart valves. In some clinical situations, combination of antiplatelet and anticoagulant therapy can be indicated. The most recent situations are a more intensive antithrombotic therapy for risk reduction in patients with atherosclerosis and temporary addition of antiplatelet drugs in patients with indication for long-term anticoagulation. Temporary combination of antiplatelet and anticoagulant drugs is usually necessary after coronary intervention in patients with atrial fibrillation. In patients with high-risk atherosclerosis, the combination of low-dose rivaroxaban and aspirin reduces major adverse cardiovascular events (myocardial infarction, stroke, cardiovascular death) and major adverse limb events. But every combination of antiplatelet and antithrombotic drugs can increase bleeding risk. Therefore, a careful assessment of thrombotic versus bleeding risk is necessary for each patient.
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Affiliation(s)
- Christine Espinola-Klein
- Center of Cardiology, Cardiology III - Angiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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