1
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Kass-Hout O, Stern J, D Tangonan R, Morsi RZ, Thind S, Kass-Hout T, Guterman L. An alternative reduced dose regimen of ticagrelor for neuroendovascular patients. Vascular 2023; 31:902-907. [PMID: 35466828 DOI: 10.1177/17085381221092858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
OBJECTIVE There is a growing use of ticagrelor in patients undergoing neuroendovascular procedures, especially those who demonstrate clopidogrel resistance. While multiple dosages are studied in the cardiology literature, the optimal dose for patients with neurological pathology has yet to be established. Here, we describe a single center experience involving 39 patients who underwent neuroendovascular procedures that then received an adjusted lower dose of ticagrelor. METHODS A retrospective chart review was performed between 2013 and 2017 for patients on dual anti-platelet therapy (DAPT) for either cervical or intracranial vascular pathologies, as well as stenting of the neurovasculature, including carotid arteries. Patients were placed on ticagrelor if their measured P2Y12 reaction units (PRU) responses to clopidogrel were outside the expected range in our center using the VerifyNow™ P2Y12 test. All patients were maintained on a dose of 45 mg twice daily except for one patient who received 22.5 mg twice daily. Responsiveness to ticagrelor were measured utilizing the VerifyNow™ P2Y12 test. RESULTS The mean number of days for follow-up post treatment initiation was 532 days. A total of 39 patients were included in the analysis. Of these, 8 patients (21%) received implantation of intracranial stents (5 patients received pipeline embolization devices, 1 patient received stent-assisted coiling, and 2 patients received intracranial stents for atherosclerotic disease). Fourteen patients (35%) received carotid angioplasty and stenting. Seventeen patients (44%) did not receive permanent implantation of a stent. All patients on the lower dose ticagrelor of 45 mg twice daily achieved responsiveness (i.e., PRU < 194). Hemorrhagic transformation of ischemic stroke occurred in one patient (2.5%). No other hemorrhagic complications were encountered. No thromboembolic events were recorded aside from one patient (2.5%) with intracranial atherosclerotic disease who had an ischemic event. CONCLUSIONS A lower dose of ticagrelor (45 mg twice daily) appears to be safe and effective in this small cohort of patients who are resistant to clopidogrel per P2Y12 testing and who have increased risk of ischemic or hemorrhagic strokes due to neurovascular pathologies and implants. Further randomized studies are required to confirm these findings.
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Affiliation(s)
- Omar Kass-Hout
- Department of Neurology, UNC REX Healthcare, Raleigh, NC, USA
| | - Joseph Stern
- Neurosciences Department, Mercy Hospital, Buffalo, NY, USA
| | - Ruth D Tangonan
- Department of Neurology, University of Chicago Medicine, Chicago, IL, USA
| | - Rami Z Morsi
- Department of Neurology, University of Chicago Medicine, Chicago, IL, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago Medicine, Chicago, IL, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Lee Guterman
- Neurosciences Department, Mercy Hospital, Buffalo, NY, USA
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2
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Kubica J, Adamski P, Niezgoda P, Kubica A, Podhajski P, Barańska M, Umińska JM, Pietrzykowski Ł, Ostrowska M, Siller-Matula JM, Badarienė J, Bartuś S, Budaj A, Dobrzycki S, Fidor Ł, Gąsior M, Gessek J, Gierlotka M, Gil R, Gorący J, Grzelakowski P, Hajdukiewicz T, Jaguszewski M, Janion M, Kasprzak J, Kern A, Klecha A, Kleinrok A, Kochman W, Krakowiak B, Legutko J, Lesiak M, Nosal M, Piotrowski G, Przybylski A, Roleder T, Skonieczny G, Sobieszek G, Tycińska A, Wojciechowski D, Wojakowski W, Wójcik J, Zielińska M, Żurakowski A, Specchia G, Gorog DA, Navarese EP. A new approach to ticagrelor-based de-escalation of antiplatelet therapy after acute coronary syndrome. A rationale for a randomized, double-blind, placebo-controlled, investigator-initiated, multicenter clinical study. Cardiol J 2021; 28:607-614. [PMID: 34096012 DOI: 10.5603/cj.a2021.0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 11/25/2022] Open
Abstract
The risk of ischemic events gradually decreases after acute coronary syndrome (ACS), reaching a stable level after 1 month, while the risk of bleeding remains steady during the whole period of dual antiplatelet treatment (DAPT). Several de-escalation strategies of antiplatelet treatment aiming to enhance safety of DAPT without depriving it of its efficacy have been evaluated so far. We hypothesized that reduction of the ticagrelor maintenance dose 1 month after ACS and its continuation until 12 months after ACS may improve adherence to antiplatelet treatment due to better tolerability compared with the standard dose of ticagrelor. Moreover, improved safety of treatment and preserved anti-ischemic benefit may also be expected with additional acetylsalicylic acid (ASA) withdrawal. To evaluate these hypotheses, we designed the Evaluating Safety and Efficacy of Two Ticagrelor-based De-escalation Antiplatelet Strategies in Acute Coronary Syndrome - a randomized clinical trial (ELECTRA-SIRIO 2), to assess the influence of ticagrelor dose reduction with or without continuation of ASA versus DAPT with standard dose ticagrelor in reducing clinically relevant bleeding and maintaining anti-ischemic efficacy in ACS patients. The study was designed as a phase III, randomized, multicenter, double-blind, investigator-initiated clinical study with a 12-month follow-up (ClinicalTrials.gov Identifier: NCT04718025; EudraCT number: 2020-005130-15).
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Affiliation(s)
- Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Niezgoda
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Przemysław Podhajski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Malwina Barańska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Julia M Umińska
- Department of Geriatrics, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Łukasz Pietrzykowski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jolanta M Siller-Matula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland.,Department of Cardiology, Medical University of Vienna, Austria
| | - Jolita Badarienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Andrzej Budaj
- Department of Cardiology, Center of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, University Hospital, Bialystok, Poland
| | - Łukasz Fidor
- Department of Cardiology, Tuchola Hospital, Tuchola, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Silesian Center for Heart Diseases, Faculty of Medicine in Zabrze, Medical University of Silesia, Zabrze, Poland
| | - Jacek Gessek
- Department of Cardiology and Intensive Cardiological Care, Specialized Municipal Hospital, Torun, Poland
| | - Marek Gierlotka
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Poland
| | - Robert Gil
- Department of Invasive Cardiology, Central Clinical Hospital MSWiA, Warsaw, Poland
| | - Jarosław Gorący
- Department of Cardiology, University Hospital No. 2, Pomeranian Medical University, Szczecin, Poland
| | - Paweł Grzelakowski
- Department of Cardiology and Cardiac Surgery, 10th Military Research Hospital and Polyclinic, Bydgoszcz, Poland
| | | | | | - Marianna Janion
- Institute of Medical Sciences, Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Jarosław Kasprzak
- 1st Department and Chair of Cardiology, Medical University of Lodz, Bieganski Hospital, Lodz, Poland
| | - Adam Kern
- Department of Cardiology and Internal Medicine, Medical Faculty, University of Warmia and Mazury in Olsztyn, Poland.,Department of Cardiology, Voivodal Specialist Hospital in Olsztyn, Poland
| | - Artur Klecha
- Department of Cardiology, Podhalanski Specialized Hospital, Nowy Targ, Poland
| | - Andrzej Kleinrok
- University of Information Technology and Management in Rzeszow, Poland.,Department of Cardiology, The Pope John Paul II Hospital in Zamosc, Poland
| | - Wacław Kochman
- The National Institute of Cardiology, Department of Cardiology, Bielanski Hospital, Warsaw, Poland
| | - Bartosz Krakowiak
- Department of Cardiology, Center for Heart Diseases, Military Hospital, Wroclaw, Poland
| | - Jacek Legutko
- Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, The John Paul II Hospital in Krakow, Poland
| | - Maciej Lesiak
- Chair and 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Nosal
- Center for Invasive Cardiology, Electrotherapy and Angiology, Krosno, Poland
| | | | | | - Tomasz Roleder
- Department of Cardiology, Provincial Hospital in Wroclaw, Poland
| | - Grzegorz Skonieczny
- Department of Cardiology and Intensive Cardiological Care, Rydygier Provincial Hospital, Torun, Poland
| | | | | | | | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Marzenna Zielińska
- Department of Interventional Cardiology, Medical University of Lodz, Poland
| | | | | | - Diana A Gorog
- Postgraduate Medical School, University of Hertfordshire, Stevenage, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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3
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Zhang WB, Liu LN, Liu Y, Wang Z. Efficacy and safety of ticagrelor monotherapy in patients following percutaneous coronary intervention: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26070. [PMID: 34011127 PMCID: PMC8137014 DOI: 10.1097/md.0000000000026070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/27/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND We aimed to systematically evaluate the efficacy and safety ticagrelor monotherapy following percutaneous coronary intervention. METHODS Online databases were searched for relevant studies (published between the years 2015 and 2020) comparing 1-month Dual antiplatelet therapy (DAPT) followed by 23-month ticagrelor monotherapy with 12-month DAPT followed by 12-month aspirin monotherapy following percutaneous coronary intervention. Primary outcomes assessed efficacy whereas secondary outcomes assessed safety. Odds ratios (OR) with 95% confidence intervals (CIs) based on a random effect model were calculated and the analysis was carried out by the RevMan 5.3 software. RESULTS Only 6 studies were selected for this meta-analytical research. The meta-analysis results: MI(OR:0.96, 95% CI:0.86-1.06, P = .40), stroke (OR:1.04, 95% CI: 0.87-1.25, P = .68), stent thrombosis (OR: 0.91,95% CI:0.76-1.10,P = .32),New-Q Wave (OR:0.85,95% CI: 0.72-1.00, P = .05), all cause death (OR:0.91, 95% CI: 0.87-0.96, P < .0001), death from cardiovascular (OR: 0.76, 95% CI: 0.58-0.99, P = .04), revascularization (OR: 0.93, 95% CI: 0.87-0.99, P = .03). Ticagrelor monotherapy was associated with a significantly lower rate of myocardial Infarction (MI), stroke, stent thrombosis, all cause death, death from cardiovascular and revascularization (OR:0.91,95% CI:0.87-0.96, P < .0001) when compared to DAPT. Besides, DAPT was associated with a significantly higher rate of BARC3 or 5 bleeding (OR:0.85, 95% CI: 0.68-1.06; P = .16) when compared to ticagrelor. When bleeding was further subdivided, minor or major bleeding was also significantly higher with DAPT (OR: 0.72, 95% CI: 0.41-1.27; P = .26). GUSTO moderate or severe bleeding was also significantly higher with DAPT (OR: 0.77, 95% CI: 0.39-1.52; P = .45). CONCLUSION Ticagrelor monotherapy after short-term dual-antiplatelet therapy (DAPT) can optimize ischemic and bleeding risks. And, it can reduce the occurrence of events outcome (MI, revascularization, stroke, stent thrombosis).
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Affiliation(s)
- Wen-bin Zhang
- The First Clinical Medical School, Shandong University of Traditional Chinese Medicine
| | - Li-nan Liu
- The First Clinical Medical School, Shandong University of Traditional Chinese Medicine
| | - Yang Liu
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhen Wang
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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4
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Adamski P, Ostrowska M, Navarese EP, Kubica J. Pharmacodynamic and clinical efficacy of reduced ticagrelor maintenance doses in patients with coronary artery disease. Curr Med Res Opin 2021; 37:195-206. [PMID: 33211543 DOI: 10.1080/03007995.2020.1854207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE An increasing body of data indicates that a reduction of ticagrelor maintenance dose (MD) in stabilized patients might improve ticagrelor's safety profile and adherence to the treatment. The aim of this review was to discuss the rationale and summarize the current pharmacodynamic and clinical outcomes-based evidence from reduced MD of ticagrelor in patients with coronary artery disease (CAD). METHODS A narrative systematic review based on a literature search using the PubMed database from its inception through to June 2020. A search strategy included a combination of relevant search terms regarding ticagrelor reduced MD. The pre-determined inclusion criteria were: (1) randomized or observational trials; (2) presentation of clinical or pharmacodynamic results; (3) evaluation of any ticagrelor MD below 90 mg BID in patients with CAD. RESULTS Studies evaluating the following ticagrelor reduced MD have been identified: 90 mg QD, 60 mg BID, 60 mg QD, 45 mg BID, 22.5 mg BID. Majority of trials assessing doses <60 mg BID were performed in Asian patients only. Antiplatelet effect of ticagrelor in CAD decreases with the dose, however even reduced MDs provide sufficient platelet inhibition, which is greater than in clopidogrel-treated patients. De-escalation of ticagrelor dose shows a propensity towards a reduced rate of bleeding and non-bleeding adverse events. CONCLUSIONS Ticagrelor doses below 90 mg BID generally show an acceptable profile of platelet inhibition. The number of studies reporting clinical outcomes in CAD patients receiving reduced MD of ticagrelor are limited, however available results indicate that in a stable setting this strategy offers improved safety with preserved efficacy in the prevention of thrombotic events.
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Affiliation(s)
- Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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5
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Kubica J, Adamski P, Niezgoda P, Alexopoulos D, Badarienė J, Budaj A, Buszko K, Dudek D, Fabiszak T, Gąsior M, Gil R, Gorog DA, Grajek S, Gurbel PA, Gruchała M, Jaguszewski MJ, James S, Jeong YH, Jilma B, Kasprzak JD, Kleinrok A, Kubica A, Kuliczkowski W, Legutko J, Lesiak M, Siller-Matula JM, Nadolny K, Pstrągowski K, Di Somma S, Specchia G, Stępińska J, Tantry US, Tycińska A, Verdoia M, Wojakowski W, Navarese EP. Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines. Cardiol J 2020; 27:661-676. [PMID: 33073857 DOI: 10.5603/cj.a2020.0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 01/23/2023] Open
Abstract
The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the Dual Antiplatelet Therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor. The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group. Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in post-acute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic therapy (DATT) appear after a longer time from ACS (more than 2 years) and/or from cessation of DAPT (more than 1 year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials.
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Affiliation(s)
- Jacek Kubica
- Collegium Medicum, Nicolaus Copernicus University, Ul. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland.
| | - Piotr Adamski
- Collegium Medicum, Nicolaus Copernicus University, Ul. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Piotr Niezgoda
- Collegium Medicum, Nicolaus Copernicus University, Ul. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Jolita Badarienė
- Clinic of Cardiac and Vascular diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Andrzej Budaj
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | | | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Ravenna, Italy
| | - Tomasz Fabiszak
- Collegium Medicum, Nicolaus Copernicus University, Ul. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Mariusz Gąsior
- IIIrd Department of Cardiology, Silesian Center for Heart Diseases, Faculty of Medicine in Zabrze, Medical University of Silesia, Zabrze, Poland
| | - Robert Gil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Hospital of the Internal Affairs and Administration Ministry, Warsaw, Poland
| | - Diana A Gorog
- Postgraduate Medicine, University of Hertfordshire, United Kingdom and Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Stefan Grajek
- Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Marcin Gruchała
- 1st Department of Cardiology, Medical University of Gdańsk, Poland
| | | | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Jarosław D Kasprzak
- 1st Department and Chair of Cardiology, Medical University of Lodz Bieganski Hospital, Lodz Poland
| | - Andrzej Kleinrok
- University of Information Technology and Management in Rzeszow, Poland.,Department of Cardiology The Pope John Paul II Hospital in Zamosc, Poland
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Poland
| | - Maciej Lesiak
- Postgraduate Medicine, University of Hertfordshire, United Kingdom and Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Jolanta M Siller-Matula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland.,Department of Cardiology, Medical University of Vienna, Austria
| | - Klaudiusz Nadolny
- Department of Emergency Medical Service, Strategic Planning University of Dabrowa Gornicza, Dabrowa Gornicza, Poland.,Faculty of Medicine, Katowice School of Technology, Katowice, Katowice, Poland
| | - Krzysztof Pstrągowski
- Collegium Medicum, Nicolaus Copernicus University, Ul. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Salvatore Di Somma
- Department of Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy
| | | | - Janina Stępińska
- Department of Intensive Cardiac Therapy, National Institute of Cardiology, Warsaw, Poland
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | | | - Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi ASL Biella, Università del Piemonte Orientale, Italy
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Eliano P Navarese
- Collegium Medicum, Nicolaus Copernicus University, Ul. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
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6
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Agewall S. Antiplatelet treatment in acute coronary syndrome. Still an issue. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 5:125-126. [PMID: 31210265 DOI: 10.1093/ehjcvp/pvz018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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7
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Kubica J, Adamski P, Buszko K, Barańska M, Sikora J, Marszałł MP, Sobczak P, Sikora A, Kuliczkowski W, Fabiszak T, Kubica A, Jilma B, Alexopoulos D, Navarese EP. Platelet inhibition with standard vs. lower maintenance dose of ticagrelor early after myocardial infarction (ELECTRA): a randomized, open-label, active-controlled pharmacodynamic and pharmacokinetic study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 5:139-148. [PMID: 30689800 DOI: 10.1093/ehjcvp/pvz004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/19/2018] [Accepted: 01/16/2019] [Indexed: 11/15/2022]
Abstract
AIMS Currently available data indicate that reduction of ticagrelor maintenance dose (MD) 1-3 years after acute myocardial infarction (AMI) not only provides sufficient platelet inhibition but also can improve ticagrelor's safety profile. The aim of this study was to compare the antiplatelet effect of reduced and standard ticagrelor MD in stable patients beginning 1 month after AMI. METHODS AND RESULTS In a single-centre, randomized, open-label, active-controlled trial, on Day 30 following AMI, 52 patients (26 in each study arm) were assigned in a 1:1 ratio to receive either reduced (60 mg b.i.d) or standard (90 mg b.i.d) ticagrelor MD for the following 2 weeks. On Day 45 after AMI the antiplatelet effect of ticagrelor was evaluated with the VASP assay and Multiplate, and there were no significant differences in platelet inhibition between patients on reduced vs. standard MD [VASP: 10.4 (5.6-22.2) vs. 14.1 (9.4-22.1) platelet reactivity index; P = 0.30; Multiplate: 30.0 (24.0-39.0) vs. 26.5 (22.0-35.0) U; P = 0.26]. Likewise, no differences were found regarding the prevalence of on-ticagrelor high platelet reactivity between patients on ticagrelor 60 mg b.i.d vs. 90 mg b.i.d (VASP: 4% vs. 8%; P = 0.67; Multiplate: 15% vs. 8%; P = 0.54). Administration of reduced MD resulted in proportionally lower plasma concentrations of ticagrelor and its active metabolite on Day 45 after AMI. CONCLUSION These results suggest that lowering ticagrelor MD 1 month after AMI confers an adequate antiplatelet effect that is comparable to the standard dose. The tested strategy warrants further research to assess its clinical efficacy and safety. CLINICALTRIALS.GOV IDENTIFIER NCT03251859.
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Affiliation(s)
- Jacek Kubica
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Piotr Adamski
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Katarzyna Buszko
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Malwina Barańska
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Joanna Sikora
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Michał Piotr Marszałł
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Przemysław Sobczak
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Adam Sikora
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Wiktor Kuliczkowski
- Department and Clinic of Cardiology, Wrocław Medical University, 213 Borowska Street, Wroclaw 50-556, Poland
| | - Tomasz Fabiszak
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Aldona Kubica
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria
| | - Dimitrios Alexopoulos
- 2nd Department of Cardiology, National and Capodistrian University of Athens, Attikon University Hospital, Rimini 1, Athens 12462, Greece
| | - Eliano Pio Navarese
- Collegium Medicum, Nicolaus Copernicus University, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland.,Interventional Cardiology and Cardiovascular Medicine Research, Cardiovascular Research Center, Mater Dei Hospital, Samuel F Hahnemann, 10, 70125 Bari, Italy.,SIRIO MEDICINE network, 13-15 Jagiellońska Street, 85-067 Bydgoszcz, Poland.,Faculty of Medicine, University of Alberta, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada
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8
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Abstract
Major considerations in the provision of healthcare are availability, affordability, accessibility, and appropriateness, especially in the setting of heart failure where disease burden is growing, developments have been rapid and newer biomarkers, diagnostic and imaging techniques, monitoring systems, devices, procedures, and drugs have all been developed in a relatively short period of time. Many monitoring and diagnostic systems have been developed but the disproportionate cost of conducting trials of their effectiveness has limited their uptake. There are added complexities, in that the utilization of doctors for the supervision of the monitoring results may be optimal in one setting and not in another because of differences in the characteristics of organization of healthcare provision, making even interpretation of the trials we have had, still difficult to interpret. New technologies are continuously changing the approach to healthcare and will reshape the structure of the healthcare systems in the future. Mobile technologies can empower patients and carers by giving them more control over their health and social care needs and reducing their dependence on healthcare professionals for monitoring their health, but a significant problem is the integration of the multitude of monitored parameters with clinical data and the recognition of intervention thresholds. Digital technology can help, but we need to prove its cost/efficacy and how it will be paid for. Governments in many European countries and worldwide are trying to establish frameworks that promote the convergence of standards and regulations for telemedicine solutions and yet simultaneously health authorities are closely scrutinizing healthcare spending, with the objective of reducing and optimizing expenditure in the provision of health services. There are multiple factors to be considered for the reimbursement models associated with the implementation of physiological monitoring yet it remains a challenge in cash-strapped health systems.
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Affiliation(s)
- Giuseppe M C Rosano
- Department of Medical Sciences, Centre for Clinical, Basic Research IRCCS San Raffaele Pisana, via della Pisana, 235, 00163 Rome, Italy
| | - Ilaria Spoletini
- Department of Medical Sciences, Centre for Clinical, Basic Research IRCCS San Raffaele Pisana, via della Pisana, 235, 00163 Rome, Italy
- Corresponding author. Tel: +39 06 5225 2409, Fax: +39 06 5225 2465,
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical, Basic Research IRCCS San Raffaele Pisana, via della Pisana, 235, 00163 Rome, Italy
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De-escalation of anti-platelet therapy in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a narrative review. Chin Med J (Engl) 2019; 132:197-210. [PMID: 30614864 PMCID: PMC6365275 DOI: 10.1097/cm9.0000000000000047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention (PCI). In current clinical situation, availability of different oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) has enabled physicians to switch among therapies owing to specific clinical scenarios. Although optimum time, loading dose and interval of transition between P2Y12 inhibitors is still controversial and needs further evidence, switching between oral inhibitors frequently occurs in clinical practice for several reasons. Data sources: This review was based on data in articles published in PubMed up to June 2018, with the following keywords “antiplatelet therapy”, “ACS”, “PCI”, “ticagrelor”, and “clopidogrel”. Study selection: Original articles and critical reviews on de-escalation strategy in ACS patients after PCI were selected. References of the retrieved articles were also screened to search for potentially relevant papers. Results: Safety concerns associated with switching between antiplatelet agents, has prompted the use of clopidogrel for patients with ACS especially after PCI as a de-escalation strategy. Practical considerations for de-escalating therapies in patients with ACS such as reducing dose of P2Y12 inhibitors or shortening duration of DAPT (followed by aspirin or P2Y12 receptor inhibitor monotherapy) as potential options are yet to be standardized and validated. Conclusions: Current review will provide an overview of the pharmacology of common P2Y12 inhibitors, definitions of de-escalation and different de-escalating strategies and its outcomes, along with possible direction to be explored in de-escalation.
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10
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Alexopoulos D, Lianos I, Vlachakis P, Sfantou D, Dragona VM, Varlamos C. De-Escalation of Treatment With Oral P2Y12 Receptor Inhibitors: Current Status and Perspectives. J Cardiovasc Pharmacol Ther 2019; 24:304-314. [DOI: 10.1177/1074248418823724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panagiotis Vlachakis
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Danai Sfantou
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vassiliki-Maria Dragona
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalambos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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11
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Kubica A, Kosobucka A, Fabiszak T, Gorog DA, Siller-Matula JM. Assessment of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention. Is there a place for newself-reported questionnaires? Curr Med Res Opin 2019; 35:341-349. [PMID: 30091642 DOI: 10.1080/03007995.2018.1510385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Non-adherence to medication regimen after myocardial infarction (MI) leads to increased morbidity and mortality and generates additional cost to the healthcare system. OBJECTIVES The aim of this systematic review was to critically discuss assessment methods of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention and the possible application of a new self-reported questionnaire. METHODS A systematic investigation of all published literature was conducted to minimize the risk of bias. A database search (PubMed, CENTRAL and Google Scholar databases) from January 1998 through December 2017. RESULTS Adequate assessment of patient adherence to treatment is necessary to understand the potential for adverse outcomes. Methods developed for adherence evaluation are classified as subjective and objective or as direct and indirect. Direct, objective measures reflect pharmacokinetics and include measurement of the drug or its metabolite concentration, evaluation of the presence of biological markers given with the drug and direct observation of patients' medication-taking behavior. Several indirect, objective methods are based on evaluation of the availability of prescribed medications assuming that medication is taken exactly as prescribed. Assessment of the effectiveness of treatment, both at the pharmacodynamic and clinical level, indirectly but objectively reflects adherence to treatment. Subjective methods, including patient-kept diaries, patient interviews and self-reported questionnaires, due to their simplicity, real-time feedback and low cost, are often used for adherence evaluation in clinical practice. CONCLUSIONS In spite of the availability, convenience and variety of methods, measuring adherence still remains a real challenge. Using a well designed questionnaire provides an opportunity to identify patients at increased risk of non-adherence and the obstacles impeding implementation of the treatment plan, allowing implementation of tailored interventions in order to improve patient medication-taking behavior.
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Affiliation(s)
- Aldona Kubica
- a Department of Health Promotion , Collegium Medicum, Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Agata Kosobucka
- a Department of Health Promotion , Collegium Medicum, Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Tomasz Fabiszak
- b Department of Cardiology and Internal Diseases , Collegium Medicum, Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Diana A Gorog
- c National Heart & Lung Institute, Imperial College , London , UK
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12
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Adamski P, Adamska U, Ostrowska M, Navarese EP, Kubica J. Evaluating current and emerging antithrombotic therapy currently available for the treatment of acute coronary syndrome in geriatric populations. Expert Opin Pharmacother 2018; 19:1415-1425. [PMID: 30132731 DOI: 10.1080/14656566.2018.1510487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute coronary syndromes (ACS) represent one of the most perilous presentations of ischemic heart disease. Temporal trends clearly demonstrate that ACS occur later and later in life. Elderly patients with ACS comprise a populous and growing group, with more than half of individuals presenting with myocardial infarction being 75 years or older. Nevertheless, geriatric patients are greatly underrepresented in the landmark ACS trials evaluating innovative pharmacological strategies. AREAS COVERED The authors critically summarize recently published research on contemporary and emerging antithrombotic therapy for the treatment of ACS in geriatric patients. EXPERT OPINION Elderly ACS patients are characterized by simultaneously increased risk of cardiovascular events and bleeding. Very few studies assessing the efficacy and safety of novel ACS pharmacotherapy in geriatric patients are currently available. Guidelines on the treatment of ACS are based on the overall results of major randomized clinical trials (RCTs), and data supporting the recommended therapy in elderly mainly derive from subanalyses of these RCTs. Properly designed and powered RCTs are necessary to properly evaluate the net effect of current and emerging pharmacotherapy in geriatric patients. Until such data are available, elderly ACS patients should receive treatment according to the general recommendations.
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Affiliation(s)
- Piotr Adamski
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Urszula Adamska
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | | | - Eliano Pio Navarese
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland.,b Interventional Cardiology and Cardiovascular Medicine Research, Inova Center for Thrombosis Research and Drug Development , Inova Heart and Vascular Institute , Falls Church , VA , USA.,c SIRIO MEDICINE Research Network, Inova Heart and Vascular Institute, Inova Center for Thrombosis Research and Drug Development , Fairfax , VA , USA
| | - Jacek Kubica
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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13
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Fournier S, Guenat F, Fournier A, Alberio L, Bonny O, Bertaggia Calderara D, Bardy D, Lauriers N, Harbaoui B, Monney P, Pascale P, Eeckhout E, Muller O. Circadian variation of ticagrelor-induced platelet inhibition in healthy adulty. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 4:166-171. [DOI: 10.1093/ehjcvp/pvy003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/19/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Florine Guenat
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Anne Fournier
- Department of Pharmacy, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Lorenzo Alberio
- Department of Hematology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Olivier Bonny
- Department of Nephrology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | | | - Daniel Bardy
- Laboratory Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Nathalie Lauriers
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Brahim Harbaoui
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Patrizio Pascale
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 21, 1011 Lausanne, Switzerland
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14
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Kosobucka A, Michalski P, Pietrzykowski Ł, Kasprzak M, Obońska K, Fabiszak T, Felsmann M, Kubica A. Adherence to treatment assessed with the Adherence in Chronic Diseases Scale in patients after myocardial infarction. Patient Prefer Adherence 2018; 12:333-340. [PMID: 29551891 PMCID: PMC5842773 DOI: 10.2147/ppa.s150435] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION A substantial subset of patients after myocardial infarction (MI) discontinue pivotal medication early after discharge. In particular, cessation of antiplatelet treatment may lead to catastrophic ischemic events. Thus, adherence to prescribed medication in patients after MI is an issue of medical and social concern. PURPOSE The aim of the study was to evaluate the level of adherence to treatment using a newly developed scale in patients after MI treated with percutaneous coronary intervention. PATIENTS AND METHODS A single-center, prospective, observational cohort clinical study with a 6-month follow-up was performed. Patients with physical or cognitive impairment, prisoners, soldiers, and family members and coworkers of the researchers were excluded from the study. The impact of selected sociodemographic and clinical factors on adherence was evaluated in 221 patients (63 women and 158 men) aged 30 to 91 years. RESULTS The results obtained with the Adherence in Chronic Diseases Scale (ACDS) ranged from 7 to 28 points; with the average and median scored being 23.35 and 24, respectively. The ACDS score reflects the level of adherence to prescribed medication. The high ACDS scores (>26 points) were obtained in 59 (26.7%) patients, intermediate scores (21-26 points) in 110 (49.8%) and low scores (<21 points) in 52 subjects (23.5%). Acute coronary syndrome (re-ACS) occurred in 18 (8.1%) patients during the follow-up period. The high-level adherence (ACDS score >26 points) was found in 11.1% of patients with re-ACS vs 28.4% of the remaining ones (P=0.1). Lower scores (mean ± standard deviation) in re-ACS patients were found for items 2 and 3 of the ACDS: 3.11±0.68 vs 3.45±0.73 (P=0.02) and 3.28±0.89 vs 3.64±0.64 (P=0.04), respectively. CONCLUSION Age and previous MI were found to be independent factors influencing adherence assessed with the ACDS.
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Affiliation(s)
- Agata Kosobucka
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- Correspondence: Agata Kosobucka, Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Lukasiewicza St 1, 85-821 Bydgoszcz, Poland, Tel +48 52 585 5806, Email
| | - Piotr Michalski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Łukasz Pietrzykowski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michał Kasprzak
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Karolina Obońska
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Tomasz Fabiszak
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mirosława Felsmann
- Laboratory of Basic Clinical Skills and Medical Simulations, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Danielak D, Karaźniewicz-Łada M, Główka F. Ticagrelor in modern cardiology - an up-to-date review of most important aspects of ticagrelor pharmacotherapy. Expert Opin Pharmacother 2017; 19:103-112. [DOI: 10.1080/14656566.2017.1421634] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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