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Mathew RO, Sidhu MS, Rihal CS, Lennon R, El-Hajjar M, Yager N, Lyubarova R, Abdul-Nour K, Weitz S, O'Cochlain DF, Murthy V, Levisay J, Marzo K, Graham J, Dzavik V, So D, Goodman S, Rosenberg YD, Pereira N, Farkouh ME. Safety and Efficacy of CYP2C19 Genotype-Guided Escalation of P2Y 12 Inhibitor Therapy After Percutaneous Coronary Intervention in Chronic Kidney Disease: a Post Hoc Analysis of the TAILOR-PCI Study. Cardiovasc Drugs Ther 2024; 38:447-457. [PMID: 36445624 PMCID: PMC10225474 DOI: 10.1007/s10557-022-07392-2] [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: 10/11/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Chronic kidney disease (CKD) is a risk factor for ischemic and bleeding events with dual antiplatelet therapy after percutaneous coronary intervention (PCI). Whether the presence of CYP2C19 loss of function (LOF) alleles modifies this risk, and whether a genotype-guided (GG) escalation of P2Y12 inhibitor therapy post PCI is safe in this population is unclear. METHODS This was a post hoc analysis of randomized patients in TAILOR PCI. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR) threshold of < 60 ml/min/1.73 m2 for CKD (n = 539) and non-CKD (n = 4276). The aggregate of cardiovascular death, stroke, myocardial infarction, stent thrombosis, and severe recurrent coronary ischemia at 12-months post-PCI was assessed as the primary endpoint. Secondary endpoint was major or minor bleeding. RESULTS Mean (standard deviation) eGFR among patients with CKD was 49.5 (8.4) ml/min/1.72 m2. Among all patients, there was no significant interaction between randomized strategy and CKD status for any endpoint. Among LOF carriers, the interaction between randomized strategy and CKD status on composite ischemic outcome was not significant (p = 0.2). GG strategy was not associated with an increased risk of bleeding in either CKD group. CONCLUSIONS In this exploratory analysis, escalation of P2Y12 inhibitor therapy following a GG strategy did not reduce the primary outcome in CKD. However, P2Y12 inhibitor escalation following a GG strategy was not associated with increased bleeding risk in CKD. Larger studies in CKD are needed. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01742117?term=TAILOR-PCI&draw=2&rank=1 . NCT01742117.
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Affiliation(s)
- Roy O Mathew
- Department of Medicine, Loma Linda VA Health Care System, 11201 Benton Street, Loma Linda, CA, 92357, USA.
| | - Mandeep S Sidhu
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA.
| | | | - Ryan Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Mohammed El-Hajjar
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Neil Yager
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Radmila Lyubarova
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | | | - Steven Weitz
- Cardiology Associates of Schenectady, Schenectady, NY, USA
| | | | - Vishakantha Murthy
- Department of Endocrine and Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Justin Levisay
- Department of Medicine, North Shore University Health System, Evanston, IL, USA
| | - Kevin Marzo
- Department of Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - John Graham
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Vlad Dzavik
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Derek So
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Shaun Goodman
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | | | | | - Michael E Farkouh
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
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2
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Tomey MI, Chyou JY. Management Considerations for Acute Coronary Syndromes in Chronic Kidney Disease. Curr Cardiol Rep 2024; 26:303-312. [PMID: 38451453 DOI: 10.1007/s11886-024-02039-0] [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] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE OF REVIEW Propensity of patients with chronic kidney disease (CKD) to adverse outcomes of acute coronary syndromes (ACS) derives, in part, from imperfection in management. Dearth of data resulting from underrepresentation of patients with CKD in ACS trials and underuse of evidence-based testing and therapy compound biological risks inherent to CKD. We sought in this narrative review to critically appraise contemporary evidence and offer suggested approaches to practicing clinicians for the optimization of ACS management in patients with CKD. RECENT FINDINGS Updated multisociety chest pain guidelines emphasize the diversity of clinical presentations of ACS, pertinent to recognition of ACS in patients with CKD. Evolving tools to predict and prevent acute kidney injury complicating invasive management of ACS serve to support improved access to and safety of percutaneous coronary intervention (PCI) in CKD patients, who remain at elevated risk. Growth in use of radial access, advances in PCI quality, incorporation of intravascular imaging, and new options and insights in pharmacotherapy contribute to an evolving calculus of ischemic and bleeding risk in ACS with bearing on management in CKD patients. Key opportunities to improve outcomes of ACS for patients with CKD center on avoiding underuse of beneficial medical and invasive therapies; enhancing safety of therapies by leveraging evidence-based strategies to prevent acute kidney injury; and devoting specific effort to investigation of ACS management in the context of CKD.
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Affiliation(s)
- Matthew I Tomey
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1030, New York, NY, 10029, USA.
| | - Janice Y Chyou
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1030, New York, NY, 10029, USA
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3
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Varian FL, Parker WAE, Fotheringham J, Storey RF. Treatment inequity in antiplatelet therapy for ischaemic heart disease in patients with advanced chronic kidney disease: releasing the evidence vacuum. Platelets 2023; 34:2154330. [DOI: 10.1080/09537104.2022.2154330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Frances L. Varian
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
| | - William A. E. Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
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4
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Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. Am J Med 2023; 136:1147-1159. [PMID: 37380060 DOI: 10.1016/j.amjmed.2023.06.013] [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: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
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Affiliation(s)
- Jitae A Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Mahboob Alam
- Texas Heart Institute and Baylor College of Medicine, Houston
| | - Salim S Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Andrew House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, Ont, Canada
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5
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Festa MC, Rasasingam S, Sharma A, Mavrakanas TA. Early Discontinuation of Aspirin Among Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention with a Drug-Eluting Stent: A Meta-Analysis. KIDNEY360 2023; 4:e1245-e1256. [PMID: 37768893 PMCID: PMC10547225 DOI: 10.34067/kid.0000000000000223] [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: 06/20/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
Key Points P2Y12 inhibitor monotherapy after 1–3 months of dual antiplatelet therapy (DAPT) decreases the risk of clinically significant bleeding when compared with 12 months of DAPT in patients with CKD treated with a drug-eluting stent. There is no significant difference in the risk of cardiovascular events with early aspirin discontinuation when compared with 12 months of DAPT post-PCI in patients with CKD. Background Conflicting evidence exists to support whether short duration of dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy reduces bleeding complications after coronary artery drug-eluting stent (DES) insertion, compared with standard 12-month DAPT, particularly among patients with CKD who are at increased risk of bleeding. Methods A MEDLINE search identified randomized trials comparing up to 3 months of DAPT followed by P2Y12 inhibitor monotherapy versus twelve months of DAPT after insertion of a DES for any indication. Trials were included if they reported ischemic or bleeding outcomes among patients with CKD. The primary outcome was a composite of all-cause mortality, cardiac or cerebrovascular events, stent thrombosis (MACE), and major or minor bleeding events. Secondary outcomes were the individual components of the primary outcome and clinically significant bleeding. The relative risk (RR) was estimated using a random-effects model. Results Seven randomized trials were included for a total of 4996 patients with CKD (14% of the trial population). Early discontinuation of aspirin was associated with a similar incidence of the primary outcome among patients with CKD compared with 12-month DAPT (RR 0.97; 95% confidence interval [95% CI] 0.73 to 1.30). The RR of MACE was also similar between the two arms (RR 1.02; 95% CI 0.85 to 1.23). The risk of clinically significant bleeding was significantly lower with early discontinuation of aspirin (RR 0.60; 95% CI 0.46 to 0.78). Conclusion P2Y12 inhibitor monotherapy after a shortened course of DAPT seems to be associated with a similar risk of ischemic events and a lower risk of bleeding events after DES insertion among patients with CKD compared with 12-month DAPT.
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Affiliation(s)
- Maria Carolina Festa
- McGill University Health Centre, Department of Medicine, Division of General Internal Medicine, Montreal, Quebec, Canada
| | - Sathiepan Rasasingam
- McGill University Health Centre, Department of Medicine, Division of Nephrology, Montreal, Quebec, Canada
| | - Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Thomas A. Mavrakanas
- McGill University Health Centre, Department of Medicine, Division of Nephrology, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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6
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Mendieta G, Mehta S, Baber U, Angiolillo DJ, Briguori C, Cohen D, Collier T, Dangas G, Dudek D, Escaned J, Gil R, Vogel B, Cao D, Spirito A, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Moliterno DJ, Ohman EM, Sardella G, Sartori S, Sharma S, Shlofmitz R, Steg PG, Han YL, Pocock S, Gibson CM, Mehran R. Bleeding and Ischemic Risks of Ticagrelor Monotherapy After Coronary Interventions. J Am Coll Cardiol 2023; 82:687-700. [PMID: 37587580 DOI: 10.1016/j.jacc.2023.05.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/09/2023] [Accepted: 05/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND In TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention), among high-risk patients undergoing percutaneous coronary intervention (PCI), ticagrelor monotherapy vs continuation of dual antiplatelet therapy (DAPT) with aspirin and ticagrelor after completing a 3-month course of DAPT was associated with reduced bleeding, without an increase in ischemic events. OBJECTIVES This investigation sought to study the clinical benefit of ticagrelor monotherapy vs DAPT by simultaneously modeling its associated potential bleeding benefits and ischemic harms on an individual patient basis. METHODS Multivariable Cox regression models for: 1) Bleeding Academic Research Consortium type 2, 3, or 5 (BARC-2/3/5); and 2) cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke (major adverse cardiac and cerebrovascular event [MACCE]) were developed using stepwise forward variable selection. The coefficients in the BARC-2/3/5 and MACCE models were used to calculate bleeding and ischemic risk scores, respectively, for each patient (excluding the coefficient for randomized treatment). RESULTS In the total study group (N = 7,119), BARC-2/3/5 occurred in 391 (5.5%) patients, and MACCE occurred in 258 (3.6%). There was a consistent reduction in bleeding events associated with ticagrelor monotherapy compared with DAPT across both bleeding and ischemic risk strata (P interaction = 0.54 and 0.11, respectively). Importantly, this benefit associated with ticagrelor monotherapy was not offset by an increase in MACCE at any level of bleeding or ischemic risk. CONCLUSIONS Three months after PCI, discontinuing aspirin and maintaining ticagrelor monotherapy reduces bleeding in both higher-bleeding risk and lower-bleeding risk patients compared with continued DAPT. This benefit does not appear to be offset by greater ischemic risk. (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention [TWILIGHT]; NCT02270242).
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Affiliation(s)
- Guiomar Mendieta
- National Center of Cardiovascular Investigations Carlos III (CNIC), Madrid, Spain
| | - Shamir Mehta
- Department of Cardiology, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Usman Baber
- Cardiovascular Disease Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - David Cohen
- Department of Cardiology, St Francis Hospital, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dariusz Dudek
- 2nd Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Health Research Institute, San Carlos Clinical Hospital (IDISCC), Complutense University of Madrid, Madrid, Spain
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kurt Huber
- Third Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - Adnan Kastrati
- German Heart Center Munich, Technical University of Munich, German Center for Cardiovascular Research (DZHK) partner site Munich Heart Alliance, Munich, Germany
| | - Upendra Kaul
- Batra Hospital and Medical Research Center, New Delhi, India
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David J Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gennaro Sardella
- Department of Cardiology, Umberto I Polyclinical University, Rome, Italy
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Shlofmitz
- Department of Cardiology, St Francis Hospital, Roslyn, New York, USA
| | - P Gabriel Steg
- Paris Cité University, Public Hospitals of Paris (AP-HP), Bichat Hospital, Paris, France
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, Liaoning, China
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - C Michael Gibson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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7
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Yun JP, Kang J, Park KW, Park K, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Chae IH, Moon KW, Park HW, Won KB, Jeon DW, Han KR, Choi SW, Ryu JK, Jeong MH, Kim HS. Prasugrel-Based De-Escalation in Patients With Acute Coronary Syndrome According to Renal Function. JACC. ASIA 2023; 3:51-61. [PMID: 36873753 PMCID: PMC9982221 DOI: 10.1016/j.jacasi.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/22/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
Background Patients with coronary artery disease and impaired renal function are at higher risk for both bleeding and ischemic adverse events after percutaneous coronary intervention (PCI). Objectives This study assessed the efficacy and safety of a prasugrel-based de-escalation strategy in patients with impaired renal function. Methods We conducted a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS study. Patients with available estimated glomerular filtration rate (eGFR) (n = 2,311) were categorized into 3 groups. (high eGFR: >90 mL/min; intermediate eGFR: 60 to 90 mL/min; and low eGFR: <60 mL/min). The end points were bleeding outcomes (Bleeding Academic Research Consortium type 2 or higher), ischemic outcomes (cardiovascular death, myocardial infarction, stent thrombosis, repeated revascularization, and ischemic stroke), and net adverse clinical event (including any clinical event) at 1-year follow-up. Results Prasugrel de-escalation was beneficial regardless of baseline renal function (P for interaction = 0.508). The relative reduction in bleeding risk from prasugrel de-escalation was higher in the low eGFR group than in both the intermediate and high eGFR groups (relative reductions, respectively: 64% (HR: 0.36; 95% CI: 0.15-0.83) vs 50% (HR: 0.50; 95% CI: 0.28-0.90) and 52% (HR: 0.48; 95% CI: 0.21-1.13) (P for interaction = 0.646). Ischemic risk from prasgurel de-escalation was not significant in all eGFR groups (HR: 1.18 [95% CI: 0.47-2.98], HR: 0.95 [95% CI: 0.53-1.69], and HR: 0.61 [95% CI: 0.26-1.39]) (P for interaction = 0.119). Conclusions In patients with acute coronary syndrome receiving PCI, prasugrel dose de-escalation was beneficial regardless of the baseline renal function.
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Affiliation(s)
- Jun Pil Yun
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyungil Park
- Dong-A University Hospital, Busan, Republic of Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, Republic of Korea
| | - In-Ho Chae
- Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | | | - Hyun Woong Park
- Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Ki-Bum Won
- Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, South Korea
| | - Dong Woon Jeon
- National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Kyoo-Rok Han
- Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Si Wan Choi
- Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jae Kean Ryu
- Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Myung Ho Jeong
- Cheonnam University Hospital, Gwangju, Republic of Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul, Republic of Korea
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Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.
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9
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P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:829-844. [PMID: 35697777 DOI: 10.1038/s41569-022-00725-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 12/15/2022]
Abstract
For 20 years, dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and a platelet P2Y12 receptor inhibitor, has been the gold standard of antithrombotic pharmacology after percutaneous coronary intervention (PCI). In the past 5 years, several investigations have challenged this paradigm by testing the efficacy and safety of P2Y12 inhibitor monotherapy (that is, without aspirin) following a short course of DAPT. Collectively, these studies suggested a reduction in the risk of major bleeding and no significant increase in thrombotic or ischaemic events compared with guideline-recommended DAPT. Current recommendations are evolving to inform clinical practice on the ideal candidates for P2Y12 inhibitor monotherapy after PCI. Generalizing the results of studies of P2Y12 inhibitor monotherapy requires a thorough understanding of their design, populations, interventions, comparators and results. In this Review, we provide an up-to-date overview on the use of P2Y12 inhibitor monotherapy after PCI, including supporting pharmacodynamic and clinical evidence, practical recommendations and future directions.
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Wang A, Xie X, Tian X, Johnston SC, Li H, Bath PM, Zuo Y, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Meng X, Wang Y. Ticagrelor-Aspirin Versus Clopidogrel-Aspirin Among CYP2C19 Loss-of-Function Carriers With Minor Stroke or Transient Ischemic Attack in Relation to Renal Function: A Post Hoc Analysis of the CHANCE-2 Trial. Ann Intern Med 2022; 175:1534-1542. [PMID: 36315949 DOI: 10.7326/m22-1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence on the risk-benefit ratio of dual antiplatelet therapies among patients with stroke and impaired renal function is limited and inconsistent. OBJECTIVE To investigate the effect of renal function on the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin treatment. DESIGN Post hoc analysis of a multicenter, randomized, double-blind, placebo-controlled trial. (ClinicalTrials.gov: NCT04078737). SETTING 202 centers in China. PATIENTS CYP2C19 loss-of-function allele carriers with minor stroke or transient ischemic attack. INTERVENTION Ticagrelor-aspirin and clopidogrel-aspirin. MEASUREMENTS Renal function was evaluated by estimated glomerular filtration rate (eGFR) levels. The primary efficacy and safety outcomes were recurrent stroke and severe or moderate bleeding within 90 days, respectively. RESULTS Among 6378 patients, 4050 (63.5%) had normal (eGFR ≥90 mL/min/1.73 m2), 2010 (31.5%) had mildly decreased (eGFR 60 to 89 mL/min/1.73 m2), and 318 (5.0%) had moderately to severely decreased (eGFR <60 mL/min/1.73 m2) renal function. The corresponding differences in recurrent stroke between ticagrelor-aspirin and clopidogrel-aspirin for normal, mildly decreased, and moderately to severely decreased renal function was -2.8 percentage points (95% CI, -4.4 to -1.3 percentage points) (hazard ratio [HR], 0.63 [CI, 0.49 to 0.81]), -0.2 percentage point (CI, -2.4 to 2.0 percentage points) (HR, 0.98 [CI, 0.69 to 1.39]), and 3.7 percentage points (CI, -2.3 to 10.1 percentage points) (HR, 1.31 [CI, 0.48 to 3.55]), respectively. Rates of severe or moderate bleeding did not substantially differ by treatment assignments across eGFR categories. LIMITATION Renal function was only evaluated by using eGFR, and the proportion of patients with severely decreased renal function was low. CONCLUSION Patients with normal, rather than impaired, renal function received greater benefit from ticagrelor-aspirin versus clopidogrel-aspirin. PRIMARY FUNDING SOURCE Ministry of Science and Technology of the People's Republic of China.
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Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xue Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, and Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China (X.T., Y.Z.)
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingting Zuo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, and Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China (X.T., Y.Z.)
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, and Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.W.)
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11
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Zhou X, Angiolillo DJ, Ortega-Paz L. P2Y 12 Inhibitor Monotherapy after Percutaneous Coronary Intervention. J Cardiovasc Dev Dis 2022; 9:jcdd9100340. [PMID: 36286292 PMCID: PMC9604207 DOI: 10.3390/jcdd9100340] [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: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
In patients with acute and chronic coronary artery disease undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) has been the cornerstone of pharmacotherapy for the past two decades. Although its antithrombotic benefit is well established, DAPT is associated with an increased risk of bleeding, which is independently associated with poor prognosis. The improvement of the safety profiles of drug-eluting stents has been critical in investigating and implementing shorter DAPT regimens. The introduction into clinical practice of newer generation oral P2Y12 inhibitors such as prasugrel and ticagrelor, which provide more potent and predictable platelet inhibition, has questioned the paradigm of standard DAPT durations after coronary stenting. Over the last five years, several trials have assessed the safety and efficacy of P2Y12 inhibitor monotherapy after a short course of DAPT in patients treated with PCI. Moreover, ongoing studies are testing the role of P2Y12 inhibitor monotherapy immediately after PCI in selected patients. In this review, we provide up-to-date evidence on the efficacy and safety of P2Y12 inhibitor monotherapy after a short period of DAPT compared to DAPT in patients undergoing PCI as well as outcomes associated with P2Y12 inhibitor monotherapy compared to aspirin for long-term prevention.
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Affiliation(s)
- Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Department of Internal Medicine, University of Alabama at Birmingham Montgomery, Montgomery, AL 36116, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Correspondence: ; Tel.: +1-904-244-3378; Fax: +1-904-244-3102
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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12
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Benefit and risk of prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with chronic kidney disease: A nationwide cohort study. Atherosclerosis 2022; 352:69-75. [PMID: 35714431 DOI: 10.1016/j.atherosclerosis.2022.05.019] [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: 03/30/2022] [Revised: 05/06/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent in patients with chronic kidney disease (CKD) is not clearly established. This study purposed to compare clinical outcomes of patients with 6-12 (standard) versus 12-24 months (prolonged) DAPT according to CKD. METHODS Using a nationwide, claim-based database, we retrospectively evaluated association between DAPT duration and clinical outcomes including death, composite ischemic event, and composite bleeding event between 1 and 3 years after PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2. Of 73,941 eligible patients, 13,425 (18.2%) had CKD and 49,019 (66%) were prescribed prolonged DAPT. Prolonged DAPT had no significant impact on the risk of clinical outcomes in patients with normal renal function. RESULTS In patients with CKD, prolonged DAPT was associated with a lower risk of all-cause death (HR 0.85, 95% CI 0.76-0.95) and composite ischemic events (HR 0.87, 95% CI 0.78-0.96) and a higher risk of composite bleeding events (HR 1.18, 95% CI 1.02-1.37). Benefit of prolonged DAPT on reducing composite ischemic event increased significantly in patients with worsened renal dysfunction (pinteraction = 0.02) while there was no significant interaction between its bleeding risk and renal dysfunction (pinteraction = 0.22). CONCLUSIONS While standard DAPT would be recommended in patients with normal renal function, tailored decision for DAPT duration would be considered in those with CKD to balance between ischemic and bleeding risks.
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13
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Crea F. Lipid lowering beyond statins and methodological issues in cardiovascular clinical trials. Eur Heart J 2022; 43:1365-1368. [PMID: 35388411 DOI: 10.1093/eurheartj/ehac158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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14
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Skalsky K, Shiyovich A, Steinmetz T, Kornowski R. Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal. J Clin Med 2022; 11:jcm11051335. [PMID: 35268426 PMCID: PMC8911484 DOI: 10.3390/jcm11051335] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023] Open
Abstract
Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.
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Affiliation(s)
- Keren Skalsky
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Correspondence: or ; Tel.: +972-39372251; Fax: +972-39372460
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Tali Steinmetz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Department of Nephrology, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
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15
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Price S, Katz J, Kaufmann CC, Huber K. The year in cardiovascular medicine 2021: acute cardiovascular care and ischaemic heart disease. Eur Heart J 2022; 43:800-806. [PMID: 34977923 PMCID: PMC9383154 DOI: 10.1093/eurheartj/ehab908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
- Susanna Price
- Consultant Cardiologist & Intensivist, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
| | | | - Christoph C Kaufmann
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), Montleartstrasse 37, 1160, Vienna, Austria
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), Montleartstrasse 37, 1160, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
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16
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Tan JWC, Chew DP, Tsui KL, Tan D, Duplyakov D, Hammoudeh A, Zhang B, Li Y, Xu K, Ong PJ, Firman D, Gamra H, Almahmeed W, Dalal J, Tam LW, Steg G, Nguyen QN, Ako J, Al Suwaidi J, Chan M, Sobhy M, Shehab A, Buddhari W, Wang Z, Fong AYY, Karadag B, Kim BK, Baber U, Chin CT, Han YL. 2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y1 2 Receptor Antagonists in the Asia-Pacific Region: Special Populations. Eur Cardiol 2021; 16:e43. [PMID: 34815751 PMCID: PMC8591619 DOI: 10.15420/ecr.2021.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022] Open
Abstract
Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.
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Affiliation(s)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | - Kin Lam Tsui
- Pamela Youde Nethersole Eastern Hospital Hong Kong, China
| | - Doreen Tan
- Department of Pharmacy, Faculty of Science, National University of Singapore Singapore
| | | | | | - Bo Zhang
- Department of Cardiology, First Affiliated Hospital, Dalian Medical University Dalian, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | - Paul J Ong
- Heart Specialist International, Mount Elizabeth Novena Hospital Singapore.,Tan Tock Seng Hospital Singapore
| | - Doni Firman
- Harapan Kita National Cardiovascular Center/Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia Harapan Kita Jakarta, Indonesia
| | - Habib Gamra
- Cardiology Department, Fattouma Bourguiba University Hospital and University of Monastir Monastir, Tunisia
| | | | - Jamshed Dalal
- Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital Mumbai, India
| | | | - Gabriel Steg
- Department of Cardiology, Hôpital Bichat Paris, France
| | - Quang N Nguyen
- Department of Cardiology, Hanoi Medical University Hanoi, Vietnam
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine Sagamihara, Kanagawa, Japan
| | | | - Mark Chan
- National University Heart Centre Singapore
| | | | - Abdulla Shehab
- College of Medicine and Health Sciences, UAE University, Al Ain United Arab Emirates
| | | | - Zulu Wang
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | | | - Bilgehan Karadag
- Istanbul University-Cerrahpasa School of Medicine Istanbul, Turkey
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine Seoul, South Korea
| | - Usman Baber
- University of Oklahoma Health Sciences Center Oklahoma City, OK, US
| | | | - Ya Ling Han
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
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17
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Parker WAE, Storey RF. Ticagrelor monotherapy in CKD: better safety at what price? Eur Heart J 2021; 42:4694-4696. [PMID: 34480540 DOI: 10.1093/eurheartj/ehab607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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