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Valgimigli M, Landi A, Angiolillo DJ, Baber U, Bhatt DL, Bonaca MP, Capodanno D, Cohen DJ, Gibson CM, James S, Kimura T, Lopes RD, Mehta SR, Montalescot G, Sibbing D, Steg PG, Stone GW, Storey RF, Vranckx P, Windecker S, Mehran R. Demystifying the Contemporary Role of 12-Month Dual Antiplatelet Therapy After Acute Coronary Syndrome. Circulation 2024; 150:317-335. [PMID: 39038086 DOI: 10.1161/circulationaha.124.069012] [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: 01/30/2024] [Accepted: 04/26/2024] [Indexed: 07/24/2024]
Abstract
For almost two decades, 12-month dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) has been the only class I recommendation on DAPT in American and European guidelines, which has resulted in 12-month durations of DAPT therapy being the most frequently implemented in ACS patients undergoing percutaneous coronary intervention (PCI) across the globe. Twelve-month DAPT was initially grounded in the results of the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial, which, by design, studied DAPT versus no DAPT rather than the optimal DAPT duration. The average DAPT duration in this study was 9 months, not 12 months. Subsequent ACS studies, which were not designed to assess DAPT duration, rather its composition (aspirin with prasugrel or ticagrelor compared with clopidogrel) were further interpreted as supportive evidence for 12-month DAPT duration. In these studies, the median DAPT duration was 9 or 15 months for ticagrelor and prasugrel, respectively. Several subsequent studies questioned the 12-month regimen and suggested that DAPT duration should either be fewer than 12 months in patients at high bleeding risk or more than 12 months in patients at high ischemic risk who can safely tolerate the treatment. Bleeding, rather than ischemic risk assessment, has emerged as a treatment modifier for maximizing the net clinical benefit of DAPT, due to excessive bleeding and no clear benefit of prolonged treatment regimens in high bleeding risk patients. Multiple DAPT de-escalation treatment strategies, including switching from prasugrel or ticagrelor to clopidogrel, reducing the dose of prasugrel or ticagrelor, and shortening DAPT duration while maintaining monotherapy with ticagrelor, have been consistently shown to reduce bleeding without increasing fatal or nonfatal cardiovascular or cerebral ischemic risks compared with 12-month DAPT. However, 12-month DAPT remains the only class-I DAPT recommendation for patients with ACS despite the lack of prospectively established evidence, leading to unnecessary and potentially harmful overtreatment in many patients. It is time for clinical practice and guideline recommendations to be updated to reflect the totality of the evidence regarding the optimal DAPT duration in ACS.
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Affiliation(s)
- Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V., A.L.)
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland (M.V., A.L.)
- Department of Cardiology, Inselspital (S.W.), University of Bern, Switzerland (M.V.)
| | - Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V., A.L.)
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland (M.V., A.L.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.)
| | - Usman Baber
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (U.B.)
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York (D.L.B.)
| | - Marc P Bonaca
- Colorado Prevention Center Clinical Research, Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (M.B.)
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C.)
| | - David J Cohen
- St Francis Hospital, Roslyn, NY (D.J.C.)
- Cardiovascular Research Foundation, New York (D.J.C.)
| | - C Michael Gibson
- Baim Institute for Clinical Research, Harvard Medical School, Harvard University, Boston, MA (C.M.G.)
| | - Stefan James
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Japan (T.K.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L.)
| | | | - Gilles Montalescot
- ACTION Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, France (G.M.)
| | - Dirk Sibbing
- Deutsches Zentrum für Herz-Kreislauf-Forschung (German Center for Cardiovascular Research), partner site Munich Heart Alliance; Ludwig-Maximilians University München, Munich, Germany; and Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany (D.S.)
| | - P Gabriel Steg
- Paris Cité University, Public Hospitals of Paris (AP-HP), Bichat Hospital, France (P.G.S.)
| | - Gregg W Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.W.S., R.M.)
| | - Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, University of Sheffield, UK (R.F.S.)
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.W.)
| | - Stephan Windecker
- Department of Cardiology, Inselspital (S.W.), University of Bern, Switzerland (M.V.)
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.W.S., R.M.)
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Nappi F. P2Y12 Receptor Inhibitor for Antiaggregant Therapies: From Molecular Pathway to Clinical Application. Int J Mol Sci 2024; 25:7575. [PMID: 39062819 PMCID: PMC11277343 DOI: 10.3390/ijms25147575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Platelets play a significant role in hemostasis, forming plugs at sites of vascular injury to limit blood loss. However, if platelet activation is not controlled, it can lead to thrombotic events, such as myocardial infarction and stroke. To prevent this, antiplatelet agents are used in clinical settings to limit platelet activation in patients at risk of arterial thrombotic events. However, their use can be associated with a significant risk of bleeding. An enhanced comprehension of platelet signaling mechanisms should facilitate the identification of safer targets for antiplatelet therapy. Over the past decade, our comprehension of the breadth and intricacy of signaling pathways that orchestrate platelet activation has expanded exponentially. Several recent studies have provided further insight into the regulation of platelet signaling events and identified novel targets against which to develop novel antiplatelet agents. Antiplatelet drugs are essential in managing atherothrombotic vascular disease. The current antiplatelet therapy in clinical practice is limited in terms of safety and efficacy. Novel compounds have been developed in response to patient variability and resistance to aspirin and/or clopidogrel. Recent studies based on randomized controlled trials and systematic reviews have definitively demonstrated the role of antiplatelet therapy in reducing the risk of cardiovascular events. Antiplatelet therapy is the recommended course of action for patients with established atherosclerosis. These studies compared monotherapy with a P2Y12 inhibitor versus aspirin for secondary prevention. However, in patients undergoing percutaneous coronary intervention, it is still unclear whether the efficacy of P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy depends on the type of P2Y12 inhibitor. This paper focuses on the advanced-stage evaluation of several promising antiplatelet drugs.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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Zhu Y, Zhang W, Dimagli A, Han L, Cheng Z, Mei J, Chen X, Wang X, Zhou Y, Xue Q, Hu J, Tang M, Wang R, Song Y, Kang L, Redfors B, Gaudino M, Zhao Q. Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial. BMJ 2024; 385:e075707. [PMID: 38862179 PMCID: PMC11165385 DOI: 10.1136/bmj-2023-075707] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVE To assess the effect of different antiplatelet strategies on clinical outcomes after coronary artery bypass grafting. DESIGN Five year follow-up of randomised Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Grafting (DACAB) trial. SETTING Six tertiary hospitals in China; enrolment between July 2014 and November 2015; completion of five year follow-up from August 2019 to June 2021. PARTICIPANTS 500 patients aged 18-80 years (including 91 (18.2%) women) who had elective coronary artery bypass grafting surgery and completed the DACAB trial. INTERVENTIONS Patients were randomised 1:1:1 to ticagrelor 90 mg twice daily plus aspirin 100 mg once daily (dual antiplatelet therapy; n=168), ticagrelor monotherapy 90 mg twice daily (n=166), or aspirin monotherapy 100 mg once daily (n=166) for one year after surgery. After the first year, antiplatelet therapy was prescribed according to standard of care by treating physicians. MAIN OUTCOME MEASURES The primary outcome was major adverse cardiovascular events (a composite of all cause death, myocardial infarction, stroke, and coronary revascularisation), analysed using the intention-to-treat principle. Time-to-event analysis was used to compare the risk between treatment groups. Multiple post hoc sensitivity analyses examined the robustness of the findings. RESULTS Follow-up at five years for major adverse cardiovascular events was completed for 477 (95.4%) of 500 patients; 148 patients had major adverse cardiovascular events, including 39 in the dual antiplatelet therapy group, 54 in the ticagrelor monotherapy group, and 55 in the aspirin monotherapy group. Risk of major adverse cardiovascular events at five years was significantly lower with dual antiplatelet therapy versus aspirin monotherapy (22.6% v 29.9%; hazard ratio 0.65, 95% confidence interval 0.43 to 0.99; P=0.04) and versus ticagrelor monotherapy (22.6% v 32.9%; 0.66, 0.44 to 1.00; P=0.05). Results were consistent in all sensitivity analyses. CONCLUSIONS Treatment with ticagrelor dual antiplatelet therapy for one year after surgery reduced the risk of major adverse cardiovascular events at five years after coronary artery bypass grafting compared with aspirin monotherapy or ticagrelor monotherapy. TRIAL REGISTRATION NCT03987373ClinicalTrials.gov NCT03987373.
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Affiliation(s)
- Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Wei Zhang
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Arnaldo Dimagli
- Department of Cardio-thoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Lin Han
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Naval Medical University (Shanghai Changhai Hospital), Shanghai, 200433, China
| | - Zhaoyun Cheng
- Department of Cardiac Surgery, Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 451464, China
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xin Chen
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Xiaowei Wang
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Yanzai Zhou
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Qing Xue
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Naval Medical University (Shanghai Changhai Hospital), Shanghai, 200433, China
| | - Junlong Hu
- Department of Cardiac Surgery, Heart Centre of Henan Provincial People's Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, 451464, China
| | - Min Tang
- Department of Cardiothoracic Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Rui Wang
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China
| | - Yuanyuan Song
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Lei Kang
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, 41345, Sweden
| | - Mario Gaudino
- Department of Cardio-thoracic Surgery, Weill Cornell Medicine, New York, NY, 10065, USA
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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Herron GC, Bates ER. Review of the Ticagrelor Trials Evidence Base. J Am Heart Assoc 2024; 13:e031606. [PMID: 38804216 PMCID: PMC11255623 DOI: 10.1161/jaha.123.031606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.
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Affiliation(s)
| | - Eric R. Bates
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
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Hasan SU, Pervez A, Shah AA, Shah SDA, Aslam M, Arshad A, Rajput AS, Zubair MM. Safety outcomes of anti-platelet therapy post coronary artery bypass graft surgery: A systematic review and network meta-analysis of randomized control trials. Perfusion 2024; 39:684-697. [PMID: 36803180 DOI: 10.1177/02676591231159513] [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: 02/22/2023]
Abstract
BACKGROUND Antiplatelet therapy is used to decrease the risk of graft failure post coronary artery bypass graft surgery. We aimed to compare dual antiplatelet therapy (DAPT) with monotherapy along with a comparison of Aspirin, Ticagrelor, Aspirin+Ticagrelor (A+T) and Aspirin+Clopidogrel (A+C) to determine the major and minor bleeding risk, risk of postoperative myocardial infarction (MI), stroke, and all-cause mortality (ACM). METHODS Randomized Controlled Trials comparing the four groups were included. Odds ratio (OR) and Absolute Risk (AR) were employed to assess the mean and standard deviation (SD) with 95% confidence intervals (CI). The Bayesian random-effects model was used for statistical analysis. Risk difference and Cochran Q tests were used to calculate rank probability (RP) and heterogeneity, respectively. RESULTS We included 10 trials, consisting of 21 arms and 3926 patients. For the risk of major and minor bleed, A + T and Ticagrelor showed the lowest mean value of 0.040 (0.043) and 0.067 (0.073), respectively, and the highest RP of being the safest group. While a direct comparison between DAPT and monotherapy resulted in an OR of 0.57 [0.34, 0.95] for the risk of minor bleed. A + T was found to have the highest RP and the lowest mean value in terms of ACM, MI, and stroke. CONCLUSION No significant difference was found between monotherapy or dual-antiplatelet therapy for the major bleeding risk safety outcome, however DAPT was found to have a significantly higher rate of minor bleeding complications post-CABG. DAPT should be considered as the antiplatelet modality of choice post-CABG.
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Affiliation(s)
| | | | - Arshad A Shah
- Dow University of Health Sciences, Karachi, Pakistan
| | - Syed DA Shah
- Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Aslam
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Anosha Arshad
- Dow University of Health Sciences, Karachi, Pakistan
| | - Amna S Rajput
- Dow University of Health Sciences, Karachi, Pakistan
| | - M Mujeeb Zubair
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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6
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Mauro MS, Finocchiaro S, Calderone D, Rochira C, Agnello F, Scalia L, Capodanno D. Antithrombotic strategies for preventing graft failure in coronary artery bypass graft. J Thromb Thrombolysis 2024; 57:547-557. [PMID: 38491265 PMCID: PMC11026197 DOI: 10.1007/s11239-023-02940-5] [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: 12/25/2023] [Indexed: 03/18/2024]
Abstract
Coronary artery bypass graft (CABG) procedures face challenges related to graft failure, driven by factors such as acute thrombosis, neointimal hyperplasia, and atherosclerotic plaque formation. Despite extensive efforts over four decades, the optimal antithrombotic strategy to prevent graft occlusion while minimizing bleeding risks remains uncertain, relying heavily on expert opinions rather than definitive guidelines. To address this uncertainty, we conducted a review of randomized clinical trials and meta-analyses of antithrombotic therapy for patients with CABG. These studies examined various antithrombotic regimens in CABG such as single antiplatelet therapy (aspirin or P2Y12 inhibitors), dual antiplatelet therapy, and anticoagulation therapy. We evaluated outcomes including the patency of grafts, major adverse cardiovascular events, and bleeding complications and also explored future perspectives to enhance long-term outcomes for CABG patients. Early studies established aspirin as a key component of antithrombotic pharmacotherapy after CABG. Subsequent randomized controlled trials focused on adding a P2Y12 inhibitor (such as clopidogrel, ticagrelor, or prasugrel) to aspirin, yielding mixed results. This article aims to inform clinical decision-making and guide the selection of antithrombotic strategies after CABG.
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Affiliation(s)
- Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Dario Calderone
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania, Italy.
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7
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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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8
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Sandner S, Gaudino M, Redfors B, Angiolillo DJ, Ben-Yehuda O, Bhatt DL, Fremes SE, Lamy A, Marano R, Mehran R, Pocock S, Rao SV, Spertus JA, Weinsaft JW, Wells G, Ruel M. One-month DAPT with ticagrelor and aspirin for patients undergoing coronary artery bypass grafting: rationale and design of the randomised, multicentre, double-blind, placebo-controlled ODIN trial. EUROINTERVENTION 2024; 20:e322-e328. [PMID: 38436365 PMCID: PMC10905196 DOI: 10.4244/eij-d-23-00699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/17/2023] [Indexed: 03/05/2024]
Abstract
The optimal antiplatelet strategy after coronary artery bypass graft (CABG) surgery in patients with chronic coronary syndromes (CCS) is unclear. Adding the P2Y12 inhibitor, ticagrelor, to low-dose aspirin for 1 year is associated with a reduction in graft failure, particularly saphenous vein grafts, at the expense of an increased risk of clinically important bleeding. As the risk of thrombotic graft failure and ischaemic events is highest early after CABG surgery, a better risk-to-benefit profile may be attained with short-term dual antiplatelet therapy followed by single antiplatelet therapy. The One Month Dual Antiplatelet Therapy With Ticagrelor in Coronary Artery Bypass Graft Patients (ODIN) trial is a prospective, randomised, double-blind, placebo-controlled, international, multicentre study of 700 subjects that will evaluate the effect of short-term dual antiplatelet therapy with ticagrelor plus low-dose aspirin after CABG in patients with CCS. Patients will be randomised 1:1 to ticagrelor 90 mg twice daily or matching placebo, in addition to aspirin 75-150 mg once daily for 1 month; after the first month, antiplatelet therapy will be continued with aspirin alone. The primary endpoint is a hierarchical composite of all-cause death, stroke, myocardial infarction, revascularisation and graft failure at 1 year. The key secondary endpoint is a hierarchical composite of all-cause death, stroke, myocardial infarction, Bleeding Academic Research Consortium (BARC) type 3 bleeding, revascularisation and graft failure at 1 year (net clinical benefit). ODIN will report whether the addition of ticagrelor to low-dose aspirin for 1 month after CABG reduces ischaemic events and provides a net clinical benefit in patients with CCS. (ClinicalTrials.gov: NCT05997693).
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Andre Lamy
- Division of Cardiac Surgery and Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Riccardo Marano
- Department of Radiological and Hematological Sciences, Section of Radiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sunil V Rao
- New York University Langone Health System, New York, NY, USA
| | - John A Spertus
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality, Kansas City, MO, USA and Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Jonathan W Weinsaft
- Department of Medicine, Greenberg Cardiology Division, Weill Cornell Medical College, New York, NY, USA
| | - George Wells
- Heart Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Maqsood MH, Levine GN, Kleiman ND, Hasdai D, Uretsky BF, Birnbaum Y. Do We Still Need Aspirin in Coronary Artery Disease? J Clin Med 2023; 12:7534. [PMID: 38137601 PMCID: PMC10743767 DOI: 10.3390/jcm12247534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Aspirin has for some time been used as a first-line treatment for acute coronary syndromes, including ST-elevation myocardial infarction, for secondary prevention of established coronary disease, and for primary prevention in patients at risk of coronary artery disease. Although aspirin has been in use for decades, the available evidence for its efficacy largely predates the introduction of other drugs, such as statins and P2Y12 inhibitors. Based on recent trials, the recommendation for aspirin use as primary prevention has been downgraded. In addition, P2Y12 inhibitors given as a single antiplatelet therapy have been associated with a lower incidence of bleeding than dual antiplatelet therapy in combination with aspirin in patients with stable and unstable coronary artery disease. The aim of this review is to discuss the role of aspirin considering the available evidence for primary prevention, secondary prevention for stable coronary artery disease or acute coronary syndromes, and after percutaneous coronary intervention or coronary artery bypass revascularization.
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Affiliation(s)
- Muhammad Haisum Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Methodist Hospital, Houston, TX 77030, USA;
| | - Glenn N. Levine
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Neal D. Kleiman
- Department of Cardiology, Section of Interventional Cardiology, Houston Methodist DeBakey Heart Center, Houston, TX 77030, USA;
| | - David Hasdai
- Department of Cardiology, Rabin Medical Center, Tel Aviv University, Petah Tikva 49200, Israel;
| | - Barry F. Uretsky
- Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
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10
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Sandner S, Redfors B, Gaudino M. Antiplatelet therapy around CABG: the latest evidence. Curr Opin Cardiol 2023; 38:484-489. [PMID: 37751394 PMCID: PMC10552805 DOI: 10.1097/hco.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The optimal antiplatelet strategy in patients after coronary artery bypass graft (CABG) surgery is unclear. We review the evidence on the efficacy and safety of DAPT after CABG and discuss potential novel antiplatelet strategies that reduce the risk of bleeding without loss of efficacy. RECENT FINDINGS Adding the potent P2Y12 inhibitor ticagrelor to aspirin for 1 year after CABG is associated with a reduction in the risk of vein graft failure, at the expense of an increased risk of clinically important bleeding. Ticagrelor monotherapy is not associated with better efficacy than aspirin alone, but is not associated with increased bleeding risk. SUMMARY Dual antiplatelet therapy (DAPT) is recommended after acute coronary syndrome events, but aspirin as single antiplatelet therapy remains the cornerstone of antithrombotic therapy in stable ischemic heart disease because of a lack of solid evidence on the benefit of DAPT on clinical outcomes. Shorter duration DAPT, based on the pathophysiology of vein graft failure, may be a promising strategy that requires testing in adequately powered randomized trials.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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11
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Gragnano F, Cao D, Pirondini L, Franzone A, Kim HS, von Scheidt M, Pettersen AÅR, Zhao Q, Woodward M, Chiarito M, McFadden EP, Park KW, Kastrati A, Seljeflot I, Zhu Y, Windecker S, Kang J, Schunkert H, Arnesen H, Bhatt DL, Steg PG, Calabrò P, Pocock S, Mehran R, Valgimigli M. P2Y 12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events. J Am Coll Cardiol 2023; 82:89-105. [PMID: 37407118 DOI: 10.1016/j.jacc.2023.04.051] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents. OBJECTIVES This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD. METHODS We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis. RESULTS Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (HR: 0.77; 95% CI: 0.66-0.90; P < 0.001). Major bleeding was similar (HR: 0.87; 95% CI: 0.70-1.09; P = 0.23) and net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors. CONCLUSIONS Given its superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Franzone
- Department of Advanced Biomedical Sciences Federico II University of Naples, Naples, Italy
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Alf-Åge R Pettersen
- Department of Cardiology, Ringerike Hospital, Vestre Viken HF, Drammen, Norway; Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Eugene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Kyung Woo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jeehoon Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, INSERM Unité 1148, Paris, France
| | - Paolo Calabrò
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
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12
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Landi A, Valgimigli M. Antithrombotic therapy in patients with established atherosclerotic coronary disease. Heart 2023:heartjnl-2022-321603. [PMID: 37142399 DOI: 10.1136/heartjnl-2022-321603] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Affiliation(s)
- Antonio Landi
- Cardiovascular Department, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università della Svizzera Italiana, Lugano, Switzerland
| | - Marco Valgimigli
- Cardiovascular Department, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università della Svizzera Italiana, Lugano, Switzerland
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13
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Ma X, Li D, Liu S, Chen Y, Zhong P. Efficacy and Safety of Ticagrelor versus Aspirin and Clopidogrel for Stroke Prevention in Patients with Vascular Disease: A Systematic Review and Meta-Analysis. Eur Neurol 2023; 86:229-241. [PMID: 37068471 DOI: 10.1159/000530504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/25/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Currently, it is still controversial to treat stroke with ticagrelor alone. The purpose of our study was to systematically review and analyze the efficacy and safety of ticagrelor on cerebrovascular outcomes in patients with vascular risk factors. METHODS The PubMed, Cochrane Library, and Embase databases were systematically searched using the keywords stroke, ticagrelor, clopidogrel, and aspirin to identify randomized controlled trials (RCTs). Primary outcomes included reported stroke, ischemic stroke, and complex events; the secondary outcome was hemorrhagic stroke. The safety outcomes included major bleeding events, major or minor bleeding, and intracranial bleeding. The pooled odds ratio (OR), hazard ratios (HRs), and 95% confidence interval (CI) were calculated. We used I2 statistics to assess statistical heterogeneity. RESULTS This meta-analysis included 15 RCTs involving 63,865 patients. Compared to the control group, ticagrelor reduced the risk of stroke (OR: 0.90; 95% CI: 0.81-0.99, p = 0.03; I2 = 3%), ischemic stroke (OR: 0.81; 95% CI: 0.74-0.90, p < 0.0001; I2 = 0%). Ticagrelor was not associated with an increased risk of all-cause mortality (OR: 0.94; 95% CI: 0.84-1.06, p = 0.31; I2 = 62%), major bleeding (OR: 1.06; 95% CI: 0.97-1.15, p = 0.20; I2 = 17%), hemorrhagic strokes (OR: 1.22, 95% CI: 0.76-1.96, p = 0.41; I2 = 0%), and intracranial hemorrhage (OR: 1.06; 95% CI: 0.78-1.43, p = 0.71; I2 = 12%). There was an increased risk of major or minor bleeding with ticagrelor compared to the control group (OR: 1.40; 95% CI: 1.19-1.66, p < 0.0001; I2 = 56%). Additional analyses demonstrated that ticagrelor reduced the risk of incident recurrent stroke (HR: 0.83; 95% CI: 0.75-0.93, p = 0.0009; I2 = 0%), recurrent ischemic stroke (HR: 0.79; 95% CI: 0.71-0.89, p < 0.0001; I2 = 0%) among patients with a history of acute ischemic stroke (AIS) or transient ischemic attack (TIA). There were no significant differences in safety outcomes. CONCLUSION Ticagrelor is slightly better than clopidogrel and aspirin in preventing stroke, especially ischemic stroke, with significant safety risks. For patients with a history of AIS/TIA, the use of ticagrelor was superior to the use of clopidogrel or aspirin in reducing the risk of subsequent stroke. We believe that ticagrelor is a potential alternative to aspirin or clopidogrel in some cases, especially for patients with CYP2C19 deficiency.
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Affiliation(s)
- Xibo Ma
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China,
| | - Danfeng Li
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
| | - Shihua Liu
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
| | - Yan Chen
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
| | - Ping Zhong
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
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14
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Sandner S, Misfeld M, Caliskan E, Böning A, Aramendi J, Salzberg SP, Choi YH, Perrault LP, Tekin I, Cuerpo GP, Lopez-Menendez J, Weltert LP, Böhm J, Krane M, González-Santos JM, Tellez JC, Holubec T, Ferrari E, Doros G, Vitarello CJ, Emmert MY. Clinical outcomes and quality of life after contemporary isolated coronary bypass grafting: a prospective cohort study. Int J Surg 2023; 109:707-715. [PMID: 36912566 PMCID: PMC10389413 DOI: 10.1097/js9.0000000000000259] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/01/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVES The objective of the European Multicenter Registry to Assess Outcomes in coronary artery bypass grafting (CABG) patients (DuraGraft Registry) was to determine clinical outcomes and quality of life (QoL) after contemporary CABG that included isolated CABG and combined CABG/valve procedures, using an endothelial damage inhibitor (DuraGraft) intraoperatively for conduit preservation. Here, we report outcomes in the patient cohort undergoing isolated CABG. METHODS The primary outcome was the composite of all-cause death, myocardial infarction (MI), or repeat revascularization (RR) [major adverse cardiac events (MACE)] at 1 year. Secondary outcomes included the composite of all-cause death, MI, RR, or stroke [major adverse cardiac and cerebrovascular events (MACCE)], and QoL. QoL was assessed with the EuroQol-5 Dimension questionnaire. Independent risk factors for MACE at 1 year were determined using Cox regression analysis. RESULTS A total of 2532 patients (mean age, 67.4±9.2 years; 82.5% male) underwent isolated CABG. The median EuroScore II was 1.4 [interquartile range (IQR), 0.9-2.3]. MACE and MACCE rates at 1 year were 6.6% and 7.8%, respectively. The rates of all-cause death, MI, RR, and stroke were 4.4, 2.0, 2.2, and 1.9%, respectively. The 30-day mortality rate was 2.3%. Age, extracardiac arteriopathy, left ventricular ejection fraction less than 50%, critical operative state, and left main disease were independent risk factors for MACE. QoL index values improved from 0.84 [IQR, 0.72-0.92] at baseline to 0.92 [IQR, 0.82-1.00] at 1 year ( P <0.0001). CONCLUSION Contemporary European patients undergoing isolated CABG have a low 1-year clinical event rate and an improved QoL.
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Affiliation(s)
| | - Martin Misfeld
- Royal Prince Alfred Hospital
- Institute of Academic Surgery at Royal Prince Alfred Hospital
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney
- Medical School, University of Sydney, Camperdown, New South Wales, Australia
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig
| | - Etem Caliskan
- Charité Universitätsmedizin Berlin
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin
| | | | | | | | - Yeong-Hoon Choi
- Kerckhoff Heart Center Bad Nauheim, Campus Kerckhoff Justus-Liebig University Giessen, Giessen
| | | | - Ilker Tekin
- Manavgat Government Hospital, Manavgat
- Bahçeşehir University Faculty of Medicine, Istanbul, Turkey
| | | | | | | | | | - Markus Krane
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | | | - Maximilian Y. Emmert
- Charité Universitätsmedizin Berlin
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Berlin
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15
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Harik L, Perezgrovas-Olaria R, Soletti G, Dimagli A, Alzghari T, An KR, Cancelli G, Gaudino M, Sandner S. Graft thrombosis after coronary artery bypass surgery and current practice for prevention. Front Cardiovasc Med 2023; 10:1125126. [PMID: 36970352 PMCID: PMC10031065 DOI: 10.3389/fcvm.2023.1125126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
Coronary artery bypass grafting (CABG) is the most frequently performed cardiac surgery worldwide. The reported incidence of graft failure ranges between 10% and 50%, depending upon the type of conduit used. Thrombosis is the predominant mechanism of early graft failure, occurring in both arterial and vein grafts. Significant advances have been made in the field of antithrombotic therapy since the introduction of aspirin, which is regarded as the cornerstone of antithrombotic therapy for prevention of graft thrombosis. Convincing evidence now exists that dual antiplatelet therapy (DAPT), consisting of aspirin and a potent oral P2Y12 inhibitor, effectively reduces the incidence of graft failure. However, this is achieved at the expense of an increase in clinically important bleeding, underscoring the importance of balancing thrombotic risk and bleeding risk when considering antithrombotic therapy after CABG. In contrast, anticoagulant therapy has proved ineffective at reducing the occurrence of graft thrombosis, pointing to platelet aggregation as the key driver of graft thrombosis. We provide a comprehensive review of current practice for prevention of graft thrombosis and discuss potential future concepts for antithrombotic therapy including P2Y12 inhibitor monotherapy and short-term DAPT.
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Affiliation(s)
- Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | | | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Kevin R. An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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16
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Zheng N, Zhong J, Chen X, Su J, Liu C, Jiang L. Prophylactic Efficacy and Safety of Antithrombotic Regimens in Patients with Stable Atherosclerotic Cardiovascular Disease (S-ASCVD): A Bayesian Network Meta-Regression Analysis. Am J Cardiovasc Drugs 2023; 23:257-267. [PMID: 36867384 DOI: 10.1007/s40256-023-00574-9] [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] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and safety of antithrombotic regimens and their combinations in preventing thrombotic incidents in patients with stable atherosclerotic cardiovascular disease (S-ASCVD). METHODS A systematic literature search was conducted in the PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases. The primary comprehensive endpoint was a major adverse cardiovascular event (MACE) composite of cardiovascular death, stroke, or myocardial infarction, while the secondary endpoints were cardiovascular death, all-cause stroke, ischemic stroke, myocardial infarction, and all-cause death. The safety endpoint was major bleeding. Bayesian network meta-regression analysis in R software was used to calculate the final effect size and to correct for the effect of follow-up time on the outcome effect size. RESULTS Twelve studies reporting 122,190 patients with eight antithrombotic regimens were included in this systematic review. For the primary composite endpoint, low-dose aspirin plus clopidogrel 75 mg (hazard ratio [HR] 0.53, 95% confidence interval [CI] 0.33-0.87) and low-dose aspirin plus rivaroxaban 2.5 mg twice daily (HR 0.53, 95% CI 0.34-0.82) showed significantly better efficacy than clopidogrel monotherapy, and the efficacy was comparable among the first two regimens. Unfortunately, none of the active regimens significantly decreased all-cause death, cardiovascular death branch, and all-cause stroke as part of the secondary endpoints. Low-dose aspirin plus ticagrelor 90 mg twice daily (HR 0.81, 95% CI 0.69-0.94) and low-dose aspirin plus ticagrelor 60 mg twice daily (HR 0.84, 95% CI 0.74-0.95) had a significant advantage in myocardial infarction compared with low-dose aspirin monotherapy, while low-dose aspirin plus 2.5 mg rivaroxaban twice daily (HR 0.62, 95% CI 0.41-0.94) was better than low-dose aspirin in the treatment of ischemic stroke. In the major bleeding branch, low-dose aspirin plus ticagrelor 90 mg twice daily (HR 2.2, 95% CI 1.70-2.90), low-dose aspirin plus ticagrelor 60 mg twice daily (HR 2.1, 95% CI 1.70-2.60), low-dose aspirin plus rivaroxaban 2.5 mg twice daily (HR 1.7, 95% CI 1.30-2.00), and rivaroxaban 5 mg twice daily (HR 1.5, 95% CI 1.20-1.90) showed higher major bleeding risk compared with low-dose aspirin. CONCLUSIONS Considering MACEs, myocardial infarction, all kinds of stroke, ischemic stroke, and major bleeding, low-dose aspirin plus rivaroxaban 2.5 mg twice daily should be considered the preferred regimen for S-ASCVD patients with low bleeding risk.
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Affiliation(s)
- Nan Zheng
- Department of Cardiovascular Medicine, Ningbo Hwamei Hospital, University of Chinese Academy of Sciences, No. 41, Northwest Street, Haishu District, Ningbo City, 315000, Zhejiang Province, China
| | - Jinyan Zhong
- Department of Cardiovascular Medicine, Ningbo Hwamei Hospital, University of Chinese Academy of Sciences, No. 41, Northwest Street, Haishu District, Ningbo City, 315000, Zhejiang Province, China
| | - Xi Chen
- School of Health, Brooks College (Sunnyvale), Milpitas, CA, USA.,Department of Epidemiology and Statistics, School of Public Health, Medical College, Zhejiang University, Hangzhou, China
| | - Jia Su
- Department of Cardiovascular Medicine, Ningbo No. 1 Hospital, Ningbo, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, China
| | - Longfu Jiang
- Department of Cardiovascular Medicine, Ningbo Hwamei Hospital, University of Chinese Academy of Sciences, No. 41, Northwest Street, Haishu District, Ningbo City, 315000, Zhejiang Province, China.
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17
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Brown MT, Bortfeld KS, Sperling LS, Wenger NK. Redefining the Roles of Aspirin across the Spectrum of Cardiovascular Disease Prevention. Curr Cardiol Rev 2023; 19:9-22. [PMID: 37132104 PMCID: PMC10636801 DOI: 10.2174/1573403x19666230502163828] [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: 10/31/2022] [Revised: 03/21/2023] [Accepted: 03/28/2023] [Indexed: 05/04/2023] Open
Abstract
Even before its role in platelet inhibition was fully characterized in the 1980s, aspirin had been incorporated into the cardiovascular disease care algorithm. Early trials examining its use in unstable angina and acute myocardial infarction revealed evidence of its protective role in the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Large trials assessing use in the primary prevention setting and optimal dosing regimens were studied in the late 1990s and early 2000s. As a cornerstone of cardiovascular care, aspirin was incorporated into primary and secondary ASCVD prevention guidelines in the United States and mechanical heart valve guidelines. However, in recent years, with significant advances in medical and interventional ASCVD therapies, scrutiny has been placed on the bleeding profile of aspirin, and guidelines have adapted to new evidence. Updates in primary prevention guidelines reserve aspirin only for patients at higher ASCVD risk and low bleeding risk - though questions remain in ASCVD risk assessment as risk-enhancing factors have proven difficult to incorporate on a population level. New thoughts regarding aspirin use in secondary prevention - especially with the concomitant use of anticoagulants - have altered recommendations as additional data accrued. Finally, a recommendation for aspirin and vitamin K antagonists with mechanical heart valves has been modified. Despite aspirin losing a foothold in cardiovascular care, new evidence has strengthened claims for its use in women at high risk for preeclampsia.
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Affiliation(s)
- Matthew T. Brown
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Laurence S. Sperling
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nanette K. Wenger
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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18
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Sandner S, Kastrati A, Niessner A, Böning A, Zeymer U, Conradi L, Danner B, Zimpfer D, Färber G, Manville E, Schunkert H, von Scheidt M, Cremer J, Attmann T, Friedrich I, Oberhoffer M, Knosalla C, Walther T, Wimmer-Greinecker G, Siepe M, Grubitzsch H, Joost A, Schaefer A, Misfeld M, Laufer G, Wiedemann D, Englberger L, Hambrecht R. Sex differences among patients receiving ticagrelor monotherapy or aspirin after coronary bypass surgery: A prespecified subgroup analysis of the TiCAB trial. Int J Cardiol 2023; 370:129-135. [PMID: 36328115 DOI: 10.1016/j.ijcard.2022.10.166] [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: 09/11/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is limited evidence on the association of sex with outcomes among patients undergoing coronary bypass surgery (CABG) and treated with ticagrelor monotherapy or aspirin. METHODS This was a pre-specified sub-analysis of TiCAB, an investigator-initiated placebo-controlled randomized trial. Primary efficacy endpoint was the composite of cardiovascular death, myocardial infarction, stroke, or repeat revascularization 1 year after CABG. Safety endpoint was BARC type 2, 3 or 5 bleeding. RESULTS A total of 280 (15.0%) women and 1579 (85.0%) men were included. Compared with men, women were older (66.1 ± 10.2 vs. 70.1 ± 9.3 years) with more acute presentation (17.0% vs 21.1%). The incidence of the primary endpoint was similar between women and men (9.2% vs. 8.9%, HR 1.08, 95%CI 0.71-1.66, P = 0.71). Cardiovascular death occurred more often in women (2.9% vs 1.0%, adjusted HR 2.87, 95%CI 1.23-6.70, P = 0.02). The incidence of bleeding was similar between the sexes (2.2% vs. 2.5%, HR 0.91, 95% CI 0.51-1.65, P = 0.77). Ticagrelor vs aspirin was associated with a similar risk of the primary endpoint in women (10.6% vs. 7.9%, HR 1.39, 95%CI 0.63-3.05, P = 0.42) and men (9.5% vs. 8.2%, HR 1.15, 95%CI 0.82-1.62, P = 0.41;pinteraction = 0.69), and a similar risk of bleeding in women (2.9% vs. 1.4%, HR 2.09, 95%CI 0.38-11.41, P = 0.40) and men (2.2% vs. 2.8%, HR 0.80, 95%CI 0.42-1.52, P = 0.49;pinteraction = 0.35). CONCLUSIONS Among women and men undergoing CABG, ticagrelor monotherapy was associated with a similar risk of the primary efficacy endpoint and bleeding compared with aspirin. The risk of cardiovascular death was increased in women irrespective of antiplatelet therapy.
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Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria.
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Germany; German Center for Cardiovascular Research, Munich, Heart Alliance, Germany
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
| | - Uwe Zeymer
- Department of Cardiology, Klinikum Ludwigshafen and Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Bernhard Danner
- Department of Cardiac, Thoracic and Vascular Surgery, University Medical Center, Göttingen, Germany
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University Graz, Graz, Austria
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Universitätsklinikum Jena, Jena, Germany
| | - Emely Manville
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Germany; German Center for Cardiovascular Research, Munich, Heart Alliance, Germany
| | - Moritz von Scheidt
- Deutsches Herzzentrum München, Technische Universität München, Germany; German Center for Cardiovascular Research, Munich, Heart Alliance, Germany
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19
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Sardella G, Beerkens FJ, Dangas G, Cao D, Baber U, Sartori S, Cohen DJ, Briguori C, Gil R, Nicolas J, Zhang Z, Dudek D, Kunadian V, Kornowski R, Weisz G, Claessen B, Marx S, Escaned J, Huber K, Collier T, Moliterno DJ, Ohman EM, Krucoff MW, Kastrati A, Steg PG, Angiolillo DJ, Mehta S, Shlofmitz R, Sharma S, Pocock S, Gibson CM, Mehran R. Ticagrelor with and without aspirin in patients with a prior coronary artery bypass graft undergoing percutaneous coronary intervention: the TWILIGHT-CABG study. EUROINTERVENTION 2022; 18:e897-e909. [PMID: 35979636 PMCID: PMC9743241 DOI: 10.4244/eij-d-22-00319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/12/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Prior coronary artery bypass graft surgery (CABG) patients undergoing percutaneous coronary intervention (PCI) are often older and present with multiple comorbidities. Ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) has emerged as an effective bleeding-avoidance strategy among high-risk patients. AIMS We aimed to examine the effects of ticagrelor with or without aspirin in prior CABG patients undergoing PCI within the TWILIGHT trial. METHODS After 3 months of ticagrelor plus aspirin, patients were randomised to either aspirin or placebo, in addition to ticagrelor, for 12 months and compared by prior CABG status. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was all-cause death, myocardial infarction (MI), or stroke. RESULTS Out of 7,119 patients, a total of 703 (10.8%) patients had prior CABG within the randomised cohort. Prior CABG patients had more comorbidities and a higher incidence of BARC type 2, 3, or 5 bleeding and death, MI or stroke at 1 year after randomisation, compared with patients without prior CABG. Ticagrelor monotherapy was associated with significantly less BARC 2, 3, or 5 bleeding among prior CABG patients compared with DAPT (4.9% vs 9.6%, hazard ratio [HR] 0.50, 95% confidence interval [CI]: 0.28 to 0.90; pinteraction=0.676) and similar rates of death, MI or stroke (10.0% vs 8.7%, HR 1.14, 95% CI: 0.70 to 1.87; pinteraction=0.484). When comparing target vessel type, treatment effects were consistent among graft- and native-vessel interventions. CONCLUSIONS In high-risk patients with prior CABG, ticagrelor monotherapy reduced bleeding without compromising ischaemic outcomes compared with ticagrelor plus aspirin.
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Affiliation(s)
- Gennaro Sardella
- Department of Cardiology, Policlinico Umberto I University, Rome, Italy
| | - Frans J Beerkens
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Dangas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy
| | - Usman Baber
- Cardiovascular Disease Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Samantha Sartori
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J Cohen
- Department of Cardiology, St. Francis Hospital & Heart Center, Roslyn, NY, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Johny Nicolas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dariusz Dudek
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - 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
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
| | - Giora Weisz
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Bimmer Claessen
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Steven Marx
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Javier Escaned
- Hospital Clínico San Carlos IdISCC, Complutense University of Madrid, Madrid, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA
| | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL , USA
| | - Shamir Mehta
- Department of Cardiology, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Richard Shlofmitz
- Department of Cardiology, St. Francis Hospital & Heart Center, Roslyn, NY, USA
| | - Samin Sharma
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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20
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Siller-Matula JM, Sandner S. Short DAPT for PCI after CABG: ready for prime time. EUROINTERVENTION 2022; 18:e868-e869. [PMID: 36468856 PMCID: PMC9743243 DOI: 10.4244/eij-e-22-00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Jolanta M Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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21
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Vergallo R, Patrono C. Antiplatelet therapy to prevent graft failure after coronary artery bypass graft: aspirin monotherapy for most, DAPT for selected few. Eur Heart J 2022; 43:4456-4457. [PMID: 36101473 DOI: 10.1093/eurheartj/ehac503] [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: 12/14/2022] Open
Affiliation(s)
- Rocco Vergallo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Catholic University of the Sacred Heart, Largo A. Gemelli, 8, 00168 Rome, Italy
| | - Carlo Patrono
- Department of Pharmacology, Catholic University of the Sacred Heart, Largo F. Vito, 1, 00168, Rome, Italy
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22
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Al-Abdouh A, Abusnina W, Mhanna M, Radideh Q, Alzu'bi H, Rmilah AA, Jabri A, Barbarawi M, Obeidat K, Alabduh T, Michos ED, Alnabelsi T, Paul TK. P2Y12 Inhibitors versus Aspirin Monotherapy for Long-term Secondary Prevention of Atherosclerotic Cardiovascular Disease Events: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2022; 47:101292. [PMID: 35764143 DOI: 10.1016/j.cpcardiol.2022.101292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with established atherosclerotic cardiovascular disease (ASCVD) need long-term antiplatelet therapy to decrease the risk of future ASCVD events. METHODS We searched PubMed, Cochrane Library, and ClinicalTrials.gov (inception through September 2021) for randomized controlled trials (RCTs) evaluating P2Y12 inhibitors versus aspirin for secondary prevention of ASCVD events. RESULTS Seven RCTs including a total of 56,982 patients were included in this analysis. The median follow-up duration was 22.8 (IQR 12) months. When P2Y12 inhibitors were compared with aspirin as long-term antiplatelet therapy for secondary prevention of ASCVD events, there was a significant decrease in the risk of myocardial infarction [RR: 0.83; 95% CI: 0.72-0.94], and stroke [RR: 0.90; 95% CI: 0.83-0.99]. However, there was no significant difference in all-cause mortality [RR: 1.02; 95% CI: 0.92-1.12], or cardiovascular mortality [RR: 0.95; 95% CI: 0.83-1.08] between P2Y12 inhibitors and aspirin users. Additionally, there was no significant difference in major bleeding events [RR: 0.88; 95% CI: 0.74-1.04], or all bleeding events [RR: 1.09; 95% CI: 0.90-1.33] between P2Y12 inhibitors and aspirin groups. CONCLUSION Use of P2Y12 inhibitor monotherapy is associated with lower rates of myocardial infarction and stroke in ASCVD patients without any significant difference in mortality, or bleeding compared to aspirin monotherapy.
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Affiliation(s)
| | - Waiel Abusnina
- Department of Cardiology, Creighton University School of Medicine, NE
| | | | - Qais Radideh
- Department of Cardiology, Creighton University School of Medicine, NE
| | - Hossam Alzu'bi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Ahmad Jabri
- Department of Cardiovascular Medicine, Case Western University (Metrohealth), Cleveland, OH
| | - Mahmoud Barbarawi
- Department of Cardiovascular Medicine, University of Connecticut, Farmington, CT
| | | | - Taqwa Alabduh
- Departments of Medicine, Yarmouk University, Irbid, Jordan
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Talal Alnabelsi
- Division of Cardiovascular Medicine, University of Kentucky, KY
| | - Timir K Paul
- Department of Medical Education, University of Tennessee at Nashville, TN
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23
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Xiang F, Lin Y, Chen B. Ticagrelor for patients undergoing coronary artery bypass grafting: A meta-analysis of randomized controlled trials. Perfusion 2022; 38:698-705. [PMID: 35403510 DOI: 10.1177/02676591221076284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Ticagrelor may be an alternative to aspirin as it provides robust and consistent platelet inhibition. However, the effect of ticagrelor treatment in patients undergoing coronary artery bypass grafting (CABG) has not been well confirmed. We conducted a meta-analysis to appraise whether ticagrelor therapy affects outcomes in CABG patients. METHODS We searched PubMed, Embase, EBSCO, and Cochrane databases from its inception up to 4 December 2020 for randomized controlled trials that assessed ticagrelor versus non-ticagrelor in patients undergoing CABG. The primary outcome was the incidence of saphenous vein graft (SVG) occlusion at 1 year after CABG. Secondary outcomes were SVG occlusion at 7 days, major adverse cardiovascular events (MACE), and bleeding requiring reoperation. RESULTS Seven trials including 4305 patients (2153 randomized to ticagrelor therapy and 2152 to non-ticagrelor therapy) were included. One-hundred and thirty of 1140 patients (11.4%) randomized to the ticagrelor group versus 175 of 1220 patients (14.3%) randomized to the non-ticagrelor group experienced SVG occlusion at 1 year after CABG. Compared to the control group, ticagrelor therapy yielded a significantly lower risk of SVG occlusion [RR 0.79 (0.64-0.97), p = 0.03]. In the subgroup analysis, ticagrelor plus aspirin compared with aspirin alone did not decrease the risk of SVG occlusion after 1 year [RR 0.65 (0.40-1.07), p = 0.09]. There was no difference in the incidence of SVG occlusion at 7 days [RR 0.67 (0.42-1.06), p = 0.09], MACE up to 1 year [RR 0.99 (0.81-1.21), p = 0.90], or bleeding requiring reoperation [RR 1.16 (0.80-1.70), p = 0.44]. CONCLUSIONS Compared with non-ticagrelor therapy, ticagrelor decreased the risk of saphenous vein graft occlusion after 1 year in patients undergoing elective CABG with saphenous vein grafting.
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Affiliation(s)
- Feng Xiang
- Department of Pharmacy, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yifeng Lin
- Department of Pharmacy, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Binwu Chen
- Department of Pharmacy, The Second Affiliated Hospital, Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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24
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Kulik A, Abreu AM, Boronat V, Kouchoukos NT, Ruel M. Ticagrelor versus aspirin 2 years after coronary bypass: Observational analysis from the TARGET trial. J Card Surg 2022; 37:1969-1977. [PMID: 35397138 DOI: 10.1111/jocs.16492] [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: 02/16/2022] [Revised: 03/02/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Compared to conventional aspirin therapy, ticagrelor did not improve vein graft patency 1 year after coronary bypass surgery (CABG) in the ticagrelor antiplatelet therapy to reduce graft events and thrombosis (TARGET) trial. However, it is unknown whether ticagrelor may impact graft patency long-term following surgery. METHODS In the TARGET multicenter trial, 250 CABG patients were randomized to aspirin 81 mg or ticagrelor 90 mg twice daily. In this observational analysis, 2 years after surgery, vein graft occlusion and clinical events were compared among subjects who agreed to a second year of double-blind study drug administration (N = 156). RESULTS Two-year graft assessment was performed for 142 patients (80 aspirin patients, 62 ticagrelor patients, 425 total grafts), with an overall 2-year graft occlusion rate of 10.6%. Vein graft occlusion at 2 years, the primary outcome of this study, did not significantly differ between the two groups (15.7% vs. 13.2%, aspirin vs. ticagrelor, p = .71). The incidence of vein grafts with any disease (stenosis or occlusion) did not significantly differ between the groups (19.4% vs. 19.8%, aspirin vs. ticagrelor, p = 1.00), and the number of patients with vein graft disease did not significantly differ between the groups (30.0% vs. 29.0%, aspirin vs. ticagrelor, p = 1.00). Vein grafts developing new disease did not significantly differ between the two groups (1.5% vs. 3.8%, aspirin vs. ticagrelor, p = .41). Freedom from major adverse cardiovascular events at 2 years was similar between the groups (p = .75). CONCLUSION Compared to conventional aspirin therapy, ticagrelor did not significantly reduce vein graft disease 2 years after CABG.
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Affiliation(s)
- Alexander Kulik
- Division of Cardiac Surgery, Department of Clinical Research, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, Florida, USA
| | - Amy M Abreu
- Division of Cardiac Surgery, Department of Clinical Research, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, Florida, USA
| | - Viviana Boronat
- Division of Cardiac Surgery, Department of Clinical Research, Boca Raton Regional Hospital, Florida Atlantic University, Boca Raton, Florida, USA
| | - Nicholas T Kouchoukos
- Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, Missouri, USA
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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25
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Sandner S, Redfors B. Ticagrelor monotherapy after CABG-Probably not at all and definitely not forever. J Card Surg 2022; 37:1978-1979. [PMID: 35396762 PMCID: PMC9322319 DOI: 10.1111/jocs.16503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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26
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Zhu Y, Hu J, Zhang M, Xue Q, Liu H, Wang R, Wang X, Cheng Z, Zhao Q. Influence of Baseline HbA1c and Antiplatelet Therapy on 1-Year Vein Graft Outcome. JACC. ASIA 2022; 2:197-206. [PMID: 36339126 PMCID: PMC9627937 DOI: 10.1016/j.jacasi.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND The influence of baseline HbA1c levels on vein graft outcomes post coronary artery bypass grafting (CABG) remains unclear. OBJECTIVE The purpose of this study was to assess the association between baseline HbA1c and 1-year vein graft patency, and the effects of antiplatelet therapy on the 1-year vein graft patency after CABG in patients with baseline HbA1c <6.5% vs ≥6.5%. METHODS We examined the subgroups with baseline HbA1c <6.5% vs ≥6.5% from the DACAB trial (NCT02201771), in which 500 patients were randomly allocated to receive ticagrelor plus aspirin (T+A), ticagrelor alone (T), or aspirin alone (A) for 1 year after CABG. The primary outcome was the vein graft patency (FitzGibbon grade A) at 1 year. RESULTS A total of 405 patients with available baseline HbA1c data were included in this subgroup analysis. Of them, there were 233 patients (678 vein grafts) with baseline HbA1c <6.5% and 172 patients (512 vein grafts) with baseline HbA1c ≥6.5%. Compared with the HbA1c <6.5% subgroup, the HbA1c ≥6.5% subgroup showed worse 1-year vein graft patency (adjusted odds ratio [OR] for nonpatency: 1.69, 95% confidence interval [CI]: 1.08-2.64). T+A showed higher vein graft patency than A in both HbA1c <6.5% (adjusted OR for nonpatency: 0.34, 95% CI: 0.15-0.75) and HbA1c ≥6.5% subgroups (adjusted OR for nonpatency: 0.45, 95% CI: 0.19-1.09), without an interaction effect (P for interaction = 0.335), whereas T did not show more significant improvement than A in both subgroups. CONCLUSIONS In the DACAB trial, lower baseline HbA1c was associated with higher vein graft patency 1 year after CABG. T+A improved 1-year vein graft patency vs A, irrespective of baseline HbA1c.
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Affiliation(s)
- Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junlong Hu
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital Heart Center, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Minlu Zhang
- Department of Cancer Control and Prevention, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Qing Xue
- Department of Cardiovascular Surgery, Changhai Hospital of Shanghai, Shanghai, China
| | - Hao Liu
- Department of Cardiothoracic Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Wang
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaowei Wang
- Department of Cardiovascular Surgery, Jiangsu Province Hospital, Nanjing, China
| | - Zhaoyun Cheng
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital Heart Center, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
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27
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Alkhalil M, Džavík V, Bhatt DL, Mehran R, Mehta SR. Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention. Curr Cardiol Rep 2022; 24:277-293. [PMID: 35294730 DOI: 10.1007/s11886-022-01645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent P2Y12 inhibitors, modified DAPT durations, and more recently, aspirin discontinuation. RECENT FINDINGS Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting. The benefit of more potent P2Y12 inhibitors such as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3-6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events. Clopidogrel is the P2Y12 inhibitor of choice, while more data are required to support the use of more potent P2Y12 inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.
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Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Vladimír Džavík
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
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Aggarwal D, Bhatia K, Chunawala ZS, Furtado RHM, Mukherjee D, Dixon SR, Jain V, Arora S, Zelniker TA, Navarese EP, Mishkel GJ, Lee CJ, Banerjee S, Bangalore S, Levisay JP, Bhatt DL, Ricciardi MJ, Qamar A. P2Y 12 inhibitor versus aspirin monotherapy for secondary prevention of cardiovascular events: meta-analysis of randomized trials. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac019. [PMID: 35919116 PMCID: PMC9242055 DOI: 10.1093/ehjopen/oeac019] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/13/2022] [Indexed: 12/24/2022]
Abstract
Aim To compare the efficacy and safety of P2Y12 inhibitor or aspirin monotherapy for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD). Methods and results Medline, Embase, and Cochrane Central databases were searched to identify randomized trials comparing monotherapy with a P2Y12 inhibitor versus aspirin for secondary prevention in patients with ASCVD (cardiovascular, cerebrovascular, or peripheral artery disease). The primary outcome was major adverse cardiac events (MACE). Secondary outcomes were myocardial infarction (MI), stroke, all-cause mortality, and major bleeding. A random-effects model was used to calculate risk ratios (RR) and the corresponding 95% confidence interval (CI) and heterogeneity among studies was assessed using the Higgins I2 value. A total of 9 eligible trials (5 with clopidogrel and 4 with ticagrelor) with 61 623 patients were included in our analyses. Monotherapy with P2Y12 inhibitors significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84-0.95, I2 = 0%) and MI by 19% (0.81, 95% CI 0.71-0.92, I2 = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke (0.85, 95% CI 0.73-1.01), or all-cause mortality (1.01, 95% CI 0.92-1.11). There was also no significant difference in the risk of major bleeding with P2Y12 inhibitor monotherapy compared with aspirin (0.94, 95% CI 0.72-1.22, I2 = 42.6%). Results were consistent irrespective of the P2Y12 inhibitor used. Conclusion P2Y12 inhibitor monotherapy for secondary prevention is associated with a significant reduction in atherothrombotic events compared with aspirin alone without an increased risk of major bleeding.
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Affiliation(s)
- Devika Aggarwal
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Kirtipal Bhatia
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | | | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.,Instituto do Coracao, Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sau Paulo, Brazil
| | - Debabrata Mukherjee
- Division of Cardiology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, MI, USA
| | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer Arora
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria
| | - Eliano P Navarese
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Gregory J Mishkel
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | | | - Sripal Bangalore
- Department of Medicine (Cardiology), New York University Grossman School of Medicine, New York, NY, USA
| | - Justin P Levisay
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark J Ricciardi
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Arman Qamar
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Rodriguez JJ, Baron LE, Munoz OC, Diaz JJ. Role of Monotherapy with a P2Y12 Inhibitor for Secondary Prevention in Patients with Established Atherosclerosis. Curr Cardiol Rep 2022; 24:87-91. [PMID: 35028815 DOI: 10.1007/s11886-021-01627-8] [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] [Accepted: 10/05/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The role of monotherapy with a P2Y12 inhibitor for secondary prevention of cardiovascular diseases has been assessed in several randomized trials. In this article, we summarize the evidence regarding P2Y12 monotherapy for secondary prevention in each one of the major vascular territories. RECENT FINDINGS Available data including a large recent meta-analysis show no differences in terms of all-cause death, vascular death, stroke, and a minor difference of the risk of myocardial infarction with P2Y12 monotherapy as compared to dual antiplatelet therapy. Overall, mono antiplatelet therapy with aspirin and the P2Y12 inhibitors appear similar in efficacy. However, there are clinical conditions that may suggest one drug regimen over another in secondary prevention. The risk of bleeding must always be weighed in each patient individually for the optimal choice of the antiplatelet regimen.
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Affiliation(s)
- Juan J Rodriguez
- Texas Tech University Health Sciences Center, El paso, TX, USA.,Facultad de Medicina, Universidad Autonoma de Bucaramanga, Bucaramanga, Colombia
| | - Luis E Baron
- Texas Tech University Health Sciences Center, El paso, TX, USA.,Facultad de Medicina, Universidad de Boyaca, Tunja, Colombia
| | - Oscar C Munoz
- Texas Tech University Health Sciences Center, El paso, TX, USA.
| | - Jonathan J Diaz
- Facultad de Medicina, Universidad Autonoma de Bucaramanga, Bucaramanga, Colombia
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Sandner S, Gaudino M, Kastrati A. Commentary: Ticagrelor monotherapy-Not for CABG? J Card Surg 2022; 37:1087-1089. [PMID: 35006614 PMCID: PMC9306719 DOI: 10.1111/jocs.16203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York, USA
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, German Center for Cardiovascular Research, Munich, Germany
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31
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6570168. [DOI: 10.1093/ejcts/ezac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Indexed: 11/14/2022] Open
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32
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6524992. [DOI: 10.1093/ejcts/ezac048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 11/14/2022] Open
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33
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Calderone D, Ingala S, Mauro MS, Angiolillo DJ, Capodanno D. Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events. Expert Rev Cardiovasc Ther 2021; 19:1097-1117. [PMID: 34915778 DOI: 10.1080/14779072.2021.2020100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Although the role of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) has been disputed, its use in secondary ASCVD prevention is well established. Recent trials of primary prevention do not suggest a significant net benefit with aspirin, whereas accruing evidence supports adopting aspirin-free strategies in the context of potent P2Y12 inhibition for the secondary prevention of selected patients undergoing percutaneous coronary intervention. AREAS COVERED This updated review aims at summarizing and appraising the pharmacological characteristics and the contemporary role of aspirin for the primary and secondary prevention of ASCVD. EXPERT OPINION Recent trials and metanalyses in the context of primary prevention highlighted a modest reduction in ischemic events with aspirin use, counterbalanced by a significant increase in bleeding events. However, ongoing studies on cancer prevention could modify the current paradigm of the unfavorable benefit-risk ratio of aspirin in patients with no overt ASCVD. Conversely, aspirin use is crucial for secondary ASCVD prevention, both in chronic and acute coronary syndromes. Nevertheless, after a brief period of dual antiplatelet therapy, patients at high bleeding risk may benefit from discontinuation of aspirin if a P2Y12 inhibitor is used, hence reducing the bleeding risk with no rebound in thrombotic events.
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Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
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34
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Kulik A, Abreu AM, Boronat V, Kouchoukos NT, Ruel M. Ticagrelor versus aspirin and vein graft patency after coronary bypass: A randomized trial. J Card Surg 2021; 37:563-570. [PMID: 34961950 DOI: 10.1111/jocs.16189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/21/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Antiplatelet therapy prevents saphenous vein graft (SVG) occlusion and improves outcomes after coronary artery bypass graft surgery (CABG). However, the optimal postoperative antiplatelet regimen remains unclear. The goal of the Ticagrelor Antiplatelet Therapy to Reduce Graft Events and Thrombosis (TARGET) trial was to assess whether early postoperative ticagrelor reduces SVG occlusion compared to conventional aspirin therapy. METHODS In this multi-center double-blind randomized trial, 250 patients who had CABG with SVG were randomized to receive either aspirin 81 mg twice daily or ticagrelor 90 mg twice daily. The primary outcome was SVG occlusion at 1 year. RESULTS Altogether, 123 patients were randomized to aspirin and 127 received ticagrelor. One-year graft assessment was performed in 202 patients (80.8%), examining 588 grafts, yielding an overall graft occlusion rate of 10.9%. The primary outcome, SVG occlusion at 1 year, did not significantly differ between the two groups (17.4% vs. 13.2%, aspirin vs. ticagrelor, p = .30). The incidence of vein grafts with any disease (stenosis or occlusion) did not significantly differ between the groups (21.5% vs. 22.3%, aspirin vs. ticagrelor, p = .90), and the number of patients with vein graft disease did not significantly differ between the groups (29.4% vs. 28.0%, aspirin vs. ticagrelor, p = .88). Freedom from major adverse cardiovascular events at 1 year was similar between the groups (p = .60). CONCLUSIONS Compared to conventional aspirin therapy, ticagrelor did not significantly reduce vein graft occlusion 1 year after CABG. Further study will assess the impact of ticagrelor on 2-year graft patency for this cohort.
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Affiliation(s)
- Alexander Kulik
- Division of Cardiac Surgery, Boca Raton Regional Hospital and Florida Atlantic University, Boca Raton, Florida, USA
| | - Amy M Abreu
- Division of Cardiac Surgery, Boca Raton Regional Hospital and Florida Atlantic University, Boca Raton, Florida, USA
| | - Viviana Boronat
- Division of Cardiac Surgery, Boca Raton Regional Hospital and Florida Atlantic University, Boca Raton, Florida, USA
| | - Nicholas T Kouchoukos
- Division of Cardiac Surgery, Missouri Baptist Medical Center, St. Louis, Missouri, USA
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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35
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Wolny R, Mintz GS, Pręgowski J, Witkowski A. Mechanisms, Prevention and Treatment of Saphenous Vein Graft Disease. Am J Cardiol 2021; 154:41-47. [PMID: 34256942 DOI: 10.1016/j.amjcard.2021.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 12/24/2022]
Abstract
Saphenous vein grafts are imperfect yet indispensable conduits commonly used for coronary artery bypass grafting. Their degeneration ultimately leading to occlusion results from the pathological response of the vein to altered blood rheology and several types of vascular injury. Surgical techniques minimizing vessel damage, and prolonged antiplatelet and lipid-lowering treatment are established methods of mitigating the degeneration process hence preventing graft occlusions. Percutaneous interventions in degenerated vein grafts carry high risk of embolization, periprocedural myocardial infarction and restenosis. Thus, native vessel should be the preferred treatment target in case of graft failure whenever technically feasible.
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36
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Björklund E, Malm CJ, Nielsen SJ, Hansson EC, Tygesen H, Romlin BS, Martinsson A, Omerovic E, Pivodic A, Jeppsson A. Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome. JAMA Netw Open 2021; 4:e2122597. [PMID: 34436610 PMCID: PMC8391102 DOI: 10.1001/jamanetworkopen.2021.22597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak. OBJECTIVE To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy. DESIGN, SETTING, AND PARTICIPANTS This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020. EXPOSURES Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only. MAIN OUTCOMES AND MEASURES Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up. RESULTS A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results. CONCLUSIONS AND RELEVANCE In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
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Affiliation(s)
- Erik Björklund
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
| | - Carl Johan Malm
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma C. Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Tygesen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Medicine, South Älvsborg Hospital, Borås, Sweden
| | - Birgitta S. Romlin
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Martinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aldina Pivodic
- Statistiska Konsultgruppen, Gothenburg, Sweden
- Department of Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Bálint A, Tornyos D, El Alaoui El Abdallaoui O, Kupó P, Komócsi A. Network Meta-Analysis of Ticagrelor for Stroke Prevention in Patients at High Risk for Cardiovascular or Cerebrovascular Events. Stroke 2021; 52:2809-2816. [PMID: 34162232 DOI: 10.1161/strokeaha.120.032670] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Alexandra Bálint
- Interventional Cardiology Department, Heart Institute, Medical School, University of Pécs, Hungary
| | - Dániel Tornyos
- Interventional Cardiology Department, Heart Institute, Medical School, University of Pécs, Hungary
| | | | - Péter Kupó
- Interventional Cardiology Department, Heart Institute, Medical School, University of Pécs, Hungary
| | - András Komócsi
- Interventional Cardiology Department, Heart Institute, Medical School, University of Pécs, Hungary
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Sandner SE, Schunkert H, Kastrati A, Wiedemann D, Misfeld M, Böning A, Tebbe U, Nowak B, Stritzke J, Laufer G, von Scheidt M. Ticagrelor monotherapy versus aspirin in patients undergoing multiple arterial or single arterial coronary artery bypass grafting: insights from the TiCAB trial. Eur J Cardiothorac Surg 2021; 57:732-739. [PMID: 31750899 DOI: 10.1093/ejcts/ezz313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We evaluated the effect of ticagrelor monotherapy on outcomes after multiple arterial grafting (MAG) or single arterial grafting (SAG) in coronary artery bypass grafting (CABG). METHODS In a post hoc, non-randomized analysis of the TiCAB (Ticagrelor in CABG; ClinicalTrials.gov NCT01755520) trial, we compared event rates for ticagrelor versus aspirin in patients undergoing MAG and SAG. Primary outcome was the composite of cardiovascular death, non-fatal myocardial infarction (MI), stroke or repeat revascularization 1 year after CABG. Secondary outcomes included individual components of the primary end point, all-cause death and bleeding. RESULTS Among 1753 patients, 998 patients underwent MAG and 755 patients underwent SAG. There was no significant difference in the 1-year primary composite outcome for ticagrelor versus aspirin with MAG [7.2% vs 7.9%; hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.57-1.43; P = 0.66] or SAG (12.3% vs 8.6%; HR 1.47, 95% CI 0.93-2.31; P = 0.10). Event rates for cardiovascular death, MI, stroke, repeat revascularization and all-cause death were similar for both treatment groups with MAG and SAG. No significant difference in major bleeding was observed for ticagrelor versus aspirin with MAG (2.6% vs 2.7%; HR 0.95, 95% CI 0.44-2.05; P = 0.90) or SAG (5.8% vs 4.0%; HR 1.49, 95% CI 0.77-2.89; P = 0.24). CONCLUSIONS In patients undergoing either MAG or SAG in the TiCAB trial, ticagrelor monotherapy compared with aspirin did not affect the rate of cardiovascular death, non-fatal MI, stroke or repeat revascularization, or the rate of bleeding, at 1 year after CABG.
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Affiliation(s)
- Sigrid E Sandner
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Heribert Schunkert
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Dominik Wiedemann
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Ulrich Tebbe
- Department of Cardiology, Angiology and Intensive Care Medicine, Hospital Lippe-Detmold, Detmold, Germany
| | - Bernd Nowak
- Cardiovascular Center Bethanien, Frankfurt, Germany
| | | | - Günther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Moritz von Scheidt
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
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39
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Sandner S, Gaudino M. Ticagrelor and CABG for acute coronary syndrome?-It is complicated. J Card Surg 2021; 36:2802-2804. [PMID: 34041780 DOI: 10.1111/jocs.15678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York City, New York, USA
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40
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Metkus TS. Searching for the ideal antiplatelet therapy for CABG patients with kidney disease. Ann Thorac Surg 2021; 113:562. [PMID: 34022214 DOI: 10.1016/j.athoracsur.2021.04.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 524, D2 600 N Wolfe St, Baltimore, MD, 21287.
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41
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Sandner SE, Schunkert H, Kastrati A, Milojevic M, Böning A, Zimpfer D, Zellmer S, Wiedemann D, Laufer G, von Scheidt M. Ticagrelor or aspirin after coronary artery bypass in patients with chronic kidney disease. Ann Thorac Surg 2021; 113:554-562. [PMID: 33819474 DOI: 10.1016/j.athoracsur.2021.03.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/19/2021] [Accepted: 03/22/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The optimal antiplatelet therapy for patients with chronic kidney disease (CKD) undergoing coronary artery bypass grafting (CABG) remains unknown. METHODS This post hoc analysis of the Ticagrelor in Coronary Artery Bypass (TiCAB) trial examined the efficacy and safety of ticagrelor versus aspirin in patients with or without CKD. Primary endpoint was the composite of cardiovascular death, stroke, myocardial infarction or revascularization (MACCE) at 1 year after CABG. Secondary endpoints included individual components of the primary endpoint, all-cause death, and major bleeding. RESULTS CKD was present in 276 of 1,843 randomized patients (15.0%). Patients with CKD versus those without CKD had higher 1-year rates of MACCE (13.0% vs. 8.3%, HR 1.63, 95% CI 1.12-2.39, P=0.01) and major bleeding (5.6% vs. 3.1%, HR 1.84, 95% CI 1.03-3.28, P=0.04). The 1-year rate of MACCE was increased with ticagrelor versus aspirin in patients with CKD (18.2% vs. 8.9%, HR 2.15, 95% CI 1.08-4.30, P=0.03), but not in patients without CKD (8.5% vs. 8.1%, HR 1.05, 95% CI 0.74-1.49, P=0.79) (Pinteraction=0.067). There was no difference in the 1-year rate of major bleeding with ticagrelor versus aspirin in patients with CKD (6.6% vs. 4.7%, HR 1.44, 95% CI 0.52-3.97, P=0.48) and without CKD (3.3% vs. 2.9%, HR 1.14, 95% CI 0.64-2.01, P=0.65). CONCLUSIONS In patients with CKD and CABG, those who received ticagrelor had a higher incidence of MACCE but a similar incidence of major bleeding compared to those who received aspirin.
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Affiliation(s)
- Sigrid E Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria.
| | - Heribert Schunkert
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, The Netherlands; Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Serbia
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Stephan Zellmer
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Moritz von Scheidt
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
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Verdoia M, Savonitto S, Dudek D, Kedhi E, De Luca G. Ticagrelor as compared to conventional antiplatelet agents in coronary artery disease: A comprehensive meta-analysis of 15 randomized trials. Vascul Pharmacol 2021; 137:106828. [DOI: 10.1016/j.vph.2020.106828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/11/2020] [Accepted: 12/28/2020] [Indexed: 01/11/2023]
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Schaefer A, Conradi L, Schneeberger Y, Reichenspurner H, Sandner S, Tebbe U, Nowak B, Stritzke J, Kastrati A, Schunkert H, von Scheidt M. Clinical outcomes of complete versus incomplete revascularization in patients treated with coronary artery bypass grafting: insights from the TiCAB trial. Eur J Cardiothorac Surg 2020; 59:ezaa330. [PMID: 33188598 DOI: 10.1093/ejcts/ezaa330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In this post hoc analysis of the Ticagrelor in coronary artery bypass grafting (CABG) trial, we aimed to analyse patients treated with CABG receiving either complete revascularization (CR) or incomplete revascularization (ICR) independent from random allocation to either ticagrelor or aspirin. METHODS Of 1859 patients enrolled in the Ticagrelor in CABG trial, 1550 patients (83.4%) received CR and 309 patients (16.6%) ICR. Outcomes were evaluated regarding all-cause mortality, cardiovascular death, myocardial infarction (MI), repeat revascularization, stroke and bleeding within 12 months after CABG. RESULTS Baseline parameters revealed significant differences regarding clinical presentation (stable angina pectoris: CR 68.9% vs ICR 71.2%, instable angina pectoris: 14.1% vs 7.8%, non-ST elevation MI: 17.0% vs 21.0%, P ˂ 0.01), lesion characteristics (chronic total occlusion: CR 91.3% vs ICR 96.8%, P ˂ 0.01), operative technique [off-pump coronary artery bypass surgery (OPCAB): CR 3.0% vs ICR 6.1%, P ˂ 0.01] and number of utilized grafts (total number of grafts: 2.69/patient vs 2.49/patient, P ˂ 0.001). ICR patients displayed a significantly increased risk of repeat revascularization [hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.16-3.16; P < 0.01] and percutaneous coronary intervention (HR 1.95, 95% CI 1.13-3.35; P < 0.05) within 12 months after CABG. Higher risk for repeat revascularization in ICR patients was independent from random allocation to either ticagrelor or aspirin and persisted after adjustment for baseline imbalances. CONCLUSIONS Patients with ICR presented more stable at the time of admission, but received less grafts, highly likely due to a higher rate of chronic total occlusion lesions and performed OPCAB. Although mortality presented no difference between groups, our results suggest that patients benefit from CR with regard to prevention of repeat revascularization.
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Affiliation(s)
- Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Yvonne Schneeberger
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Sigrid Sandner
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulrich Tebbe
- Department of Cardiology, Angiology, and Intensive Care Medicine, District Hospital Lippe-Detmold, Detmold, Germany
| | - Bernd Nowak
- CCB, Cardiovascular Center Bethanien, Frankfurt am Main, Germany
| | - Jan Stritzke
- Lanserhof Sylt, Marienstein Privatklinik, List, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Abstract
PURPOSE OF REVIEW Coronary artery bypass graft (CABG) surgery remains the gold-standard treatment for multivessel and left main coronary artery disease. Despite significant improvement in cardiovascular outcomes, patients undergoing CABG remain at risk for recurrent adverse ischemic events and other cardiovascular outcomes (coronary revascularisation, stroke, cardiac death, etc.). The purpose of this review is to summarize the most recent evidence in pharmacological preventive therapies addressing the residual cardiovascular risk in patients who have undergone CABG. RECENT FINDINGS Novel cardiovascular pharmacological preventive strategies targeting inflammatory, metabolic and prothrombotic (antiplatelet and anticoagulation) pathways have been recently assessed, with promising results for secondary prevention after CABG. SUMMARY Secondary prevention is an essential part of postoperative care after CABG. Novel lipid-lowering and glucose-controlling agents suggest a strong and consistent benefit on native coronary artery disease and overall cardiovascular outcomes. The role and the choice of enhanced antiplatelet/anticoagulation/lipid/glucose-modulating therapies following CABG should be better defined and deserves further investigation. Additional studies are required to identify new therapeutic target addressing the specific multifactorial nature of the graft CV disease and identifying the best preventive strategies for long-term graft patency.
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Khan H, Gallant R, Jain S, Al-Omran M, De Mestral C, Greco E, Wheatcroft M, Alazonni A, Abdin R, Rand ML, Ni H, Qadura M. Ticagrelor as an Alternative Antiplatelet Therapy in Cardiac Patients Non-Sensitive to Aspirin. ACTA ACUST UNITED AC 2020; 56:medicina56100519. [PMID: 33023261 PMCID: PMC7600331 DOI: 10.3390/medicina56100519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022]
Abstract
Background and Objectives: Aspirin (acetylsalicylic acid-ASA) is a first-line antiplatelet therapy provided to patients with coronary artery disease (CAD). However, it has been demonstrated that 20-30% of these patients are non-sensitive to their ASA therapy. ASA non-sensitivity is a phenomenon where low-dose ASA (81-325 mg) does not completely inhibit arachidonic-acid-induced platelet aggregation, putting patients at risk of adverse cardio-thrombotic events. Ticagrelor is a P2Y12 receptor inhibitor and alternative antiplatelet that has been approved to reduce the risk of stroke, myocardial infarction, and overall cardiovascular-related death. In this study, we aimed to identify ASA non-sensitive patients and evaluate if they would be sensitive to ticagrelor. Materials and Methods: For this pilot study, thirty-eight patients with CAD taking 81 mg ASA were recruited. Blood samples were collected from each patient and platelet rich plasma (PRP) from each sample was isolated. Light-transmission aggregometry (LTA) was used to determine baseline ASA sensitivity in each patient using 0.5 mg/mL arachidonic acid as a platelet agonist. Patients with ≥20% maximal platelet aggregation after activation were considered ASA non-sensitive. Fresh PRP samples from all patients were then spiked with a clinical dosage of ticagrelor (3 μM-approximately equivalent to a loading dose of 180 mg ticagrelor). Sensitivity was determined using LTA and 5 μM ADP as a platelet agonist. Patients with ≥46% maximal platelet aggregation were considered ticagrelor non-sensitive. Results: Of the 38 CAD patients taking 81 mg ASA, 32% (12/38) were non-sensitive to their 81 mg ASA therapy. All 38 of the recruited patients (100%) were sensitive to ticagrelor ex vivo. In conclusion, we were able to identify ASA non-sensitivity using LTA and determine that ASA non-sensitive patients were sensitive to ticagrelor. Conclusions: Our results suggest that ticagrelor is a promising alternative therapy for patients who are non-sensitive to ASA.
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Affiliation(s)
- Hamzah Khan
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
| | - Reid Gallant
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (R.G.); (H.N.)
| | - Shubha Jain
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (R.G.); (H.N.)
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Charles De Mestral
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (R.G.); (H.N.)
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Elisa Greco
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Mark Wheatcroft
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Ashraf Alazonni
- Division of Cardiology, Scarborough Health Network, Toronto, ON M1P 2T7, Canada;
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada;
| | - Margaret L. Rand
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada;
- Departments of Biochemistry and Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
- Translational Medicine, Research Institute; Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Heyu Ni
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (R.G.); (H.N.)
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada;
| | - Mohammad Qadura
- Division of Vascular Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (H.K.); (S.J.); (M.A.-O.); (C.D.M.); (E.G.); (M.W.)
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada; (R.G.); (H.N.)
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Correspondence: ; Tel.: +1-416-864-6047
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Gupta S, Belley-Cote EP, Panchal P, Pandey A, Basha A, Pallo L, Rochwerg B, Mehta S, Schwalm JD, Whitlock RP. Antiplatelet therapy and coronary artery bypass grafting: a systematic review and network meta-analysis. Interact Cardiovasc Thorac Surg 2020; 31:354-363. [DOI: 10.1093/icvts/ivaa115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/15/2020] [Accepted: 06/01/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Acetylsalicylic acid (ASA) monotherapy is the standard of care after coronary artery bypass grafting (CABG), but the benefits of more intense antiplatelet therapy, specifically dual antiplatelet therapy (DAPT), require further exploration in CABG patients. We performed a network meta-analysis to compare the effects of various antiplatelet regimens on saphenous vein graft patency, mortality, major adverse cardiovascular events and bleeding among CABG patients.
METHODS
We searched Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval Systems Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, American College of Physicians Journal Club and conference proceedings for randomized controlled trials. Screening, data extraction, risk of bias assessment and Grading of Recommendations Assessment, Development and Evaluation were performed in duplicate. We conducted a random effect Bayesian network meta-analysis including both direct and indirect comparisons.
RESULTS
We included 43 randomized controlled trials studying 15 511 patients. DAPT with low-dose ASA and ticagrelor [odds ratio (OR) 2.53, 95% credible interval (CrI) 1.35–4.72; I2 = 55; low certainty] or clopidogrel (OR 1.56, 95% CrI 1.02–2.39; I2 = 55; very low certainty) improved saphenous vein graft patency when compared to low-dose ASA monotherapy. DAPT with low-dose ASA and ticagrelor was associated with lower mortality (OR 0.52, 95% CrI 0.30–0.87; I2 = 14; high certainty) and lower major adverse cardiovascular events (OR 0.63, 95% CrI 0.44–0.91; I2 = 0; high certainty) when compared to low-dose ASA monotherapy. Based on moderate certainty evidence, DAPT was associated with an increase in major bleeding.
CONCLUSIONS
Our results suggest that DAPT improves saphenous vein graft patency, mortality and major adverse cardiovascular event. As such, surgeons and physicians should consider re-initiating DAPT for acute coronary syndrome patients after their CABG, at the expense of an increased risk for major bleeding.
Clinical trial registration
International Prospective Register of Systematic Reviews ID Number CRD42019127695
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Affiliation(s)
- Saurabh Gupta
- Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Puru Panchal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Arjun Pandey
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ameen Basha
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Lindsay Pallo
- Faculty of Sciences, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - J -D Schwalm
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Richard P Whitlock
- Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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Pujade I, Perino J, Mathieu C, Arnaud M, Raschi E, Gatti M, Bezin J, Salvo F. Risk of bradyarrhythmia related to ticagrelor: A systematic review and meta-analysis. Pharmacol Res 2020; 160:105089. [PMID: 32687950 DOI: 10.1016/j.phrs.2020.105089] [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: 01/17/2020] [Revised: 07/01/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Ticagrelor was related to bradycardia in DISPERSE-II trial. This risk has been integrated into the European risk-management plan, and its use is warned in at-risk patients. Nevertheless, this risk was not systematically assessed nor measured. OBJECTIVES To estimate the risk of bradyarrhythmia associated with ticagrelor. STUDY DESIGN Systematic review and meta-analysis. DATA-SOURCE MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ISI web of Science, clinicaltrial.gov, clinicaltrialsregister.eu. STUDY SELECTION Randomized controlled trials (RCTs) and observational studies in patients treated with ticagrelor or comparator(s). META-ANALYSIS Risk of bias in each RCT was assessed using Cochrane tool. Relative Risks (RR) with 95 % confidence intervals (95 %CI) were calculated for each RCT, and pooled using fixed-effect or random-effects models, when appropriate. Subgroup and sensitivity analyses were performed. A potential publication bias was searched. RESULTS Among 82 eligible studies, event data were missing for 56 studies, due to detected reporting bias (i.e. inability to confirm zero events). Fifteen RCTs were selected and the combined RR of bradyarrhythmia was 1.15 (95 %CI 1.05-1.26), and 1.29 (1.02-1.65) for severe bradyarrhythmia. The risk appeared to be dose dependent. Restricting the analysis only to RCTs performed in patients without previous bradyarrhythmia resulted in a non-increased risk. CONCLUSION This meta-analysis confirmed the risk of bradyarrhythmia or severe bradyarrhythmia related to ticagrelor, and its use in patients without previous bradycardia was effective in preventing it. The evidence coming from this meta-analysis was low to moderate due to missing outcome in 2/3 of eligible studies. Waiting for access to these data, the use of ticagrelor in patients with risk factors of bradycardias should be avoided.
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Affiliation(s)
- Iris Pujade
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France
| | - Justine Perino
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France
| | - Clément Mathieu
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France
| | - Mickael Arnaud
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, I-40126, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, I-40126, Italy
| | - Julien Bezin
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France
| | - Francesco Salvo
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France.
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Wollner G, Zimpfer D, Manduric M, Laufer G, Rieger A, Sandner SE. Outcomes of coronary artery bypass grafting in patients with human immunodeficiency virus infection. J Card Surg 2020; 35:2543-2549. [PMID: 32652674 PMCID: PMC7586791 DOI: 10.1111/jocs.14828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background With early and effective antiretroviral therapy and improved survival for persons living with human immunodeficiency virus infection (PLHIV), this patient population now faces an increasingly elevated risk of cardiovascular disease. However, the data on outcomes after coronary artery bypass grafting (CABG) for revascularization of coronary artery disease (CAD) in HIV+ patients is limited. Methods We conducted a retrospective analysis of 16 patients undergoing isolated CABG at the Medical University of Vienna from 2005 to 2018, who were HIV+ on admission. The primary endpoint of the study was survival. Secondary endpoints included the components of major adverse cardiac and cerebrovascular events (MACCE): cardiovascular death, stroke, myocardial infarction (MI), and repeat revascularization. Results Patients were followed for a median of 49 months (range, 7‐142 months). Survival was 100% and 90% at 1 and 3 years after CABG, respectively. There were no strokes. MI and subsequent repeat revascularization were observed in two patients. Conclusion CABG provides excellent short‐ and midterm survival and freedom from MACCE in HIV+ patients with CAD requiring revascularization.
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Affiliation(s)
- Gregor Wollner
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marina Manduric
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Armin Rieger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Sigrid E Sandner
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Hesterberg K, Rawal A, Khan S, Rashid A, Jones D, Siddiqui T, Khader TA, Nayyar M, Shah R. A Meta-Analysis Comparing Aspirin Alone Versus Dual Antiplatelet Therapy for the Prevention of Venous Graft Failure Following Coronary Artery Bypass Surgery. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:792-796. [DOI: 10.1016/j.carrev.2019.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/04/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
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Chiarito M, Sanz-Sánchez J, Cannata F, Cao D, Sturla M, Panico C, Godino C, Regazzoli D, Reimers B, De Caterina R, Condorelli G, Ferrante G, Stefanini GG. Monotherapy with a P2Y 12 inhibitor or aspirin for secondary prevention in patients with established atherosclerosis: a systematic review and meta-analysis. Lancet 2020; 395:1487-1495. [PMID: 32386592 DOI: 10.1016/s0140-6736(20)30315-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Antiplatelet therapy is recommended among patients with established atherosclerosis. We compared monotherapy with a P2Y12 inhibitor versus aspirin for secondary prevention. METHODS In this systematic review and meta-analysis, all randomised trials comparing P2Y12 inhibitor with aspirin monotherapy for secondary prevention in patients with cerebrovascular, coronary, or peripheral artery disease were evaluated for inclusion. On Dec 18, 2019, we searched PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials. Additionally, we reviewed references from identified articles and searched abstracts from 2017 to 2019 presented at relevant scientific meetings. Data about year of publication, inclusion and exclusion criteria, sample size, baseline patients' features including the baseline condition determining study inclusion (ie, cerebrovascular, coronary, or peripheral artery disease), P2Y12 inhibitor type and dosage, aspirin dosage, endpoint definitions, effect estimates, follow-up duration, and percentage of patients lost to follow-up were collected. Odds ratios (ORs) and 95% CIs were used as metric of choice for treatment effects with random-effects models. Co-primary endpoints were myocardial infarction and stroke. Key secondary endpoints were all-cause death and vascular death. Heterogeneity was assessed with the I2 index. This study is registered with PROSPERO (CRD42018115037). FINDINGS A total of nine randomised trials were identified and included in this study, and 42 108 patients randomly allocated to a P2Y12 inhibitor (n=21 043) or aspirin (n=21 065) were included in our analyses. Patients who received a P2Y12 inhibitor had a borderline reduction for the risk of myocardial infarction compared with those who received aspirin (OR 0·81 [95% CI 0·66-0·99]; I2=10·9%). Risks of stroke (OR 0·93 [0·82-1·06]; I2=34·5%), all-cause death (OR 0·98 [0·89-1·08]; I2=0%), and vascular death (OR 0·97 [0·86-1·09]; I2=0%) did not differ between patients who received a P2Y12 inhibitor and those who received aspirin. Similarly, the risk of major bleeding (OR 0·90 [0·74-1·10]; I2=3·9%) did not differ between patients who received a P2Y12 inhibitor and those who received aspirin. The number needed to treat to prevent one myocardial infarction with P2Y12 inhibitor monotherapy was 244 patients. Findings were consistent regardless of the type of P2Y12 inhibitor used. INTERPRETATION Compared with aspirin monotherapy, P2Y12 inhibitor monotherapy is associated with a risk reduction for myocardial infarction and a comparable risk of stroke in the setting of secondary prevention. The benefit of P2Y12 inhibitor monotherapy is of debatable clinical relevance, in view of the high number needed to treat to prevent a myocardial infarction and the absence of any effect on all-cause and vascular mortality. FUNDING Italian Ministry of Education.
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Affiliation(s)
- Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Jorge Sanz-Sánchez
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Davide Cao
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Matteo Sturla
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cristina Panico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Damiano Regazzoli
- Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Raffaele De Caterina
- University of Pisa, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giuseppe Ferrante
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy.
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