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Jiang Z, Liu L, Bundhun PK. Cardiovascular Outcomes Observed with Ticagrelor versus Clopidogrel in Type 2 Diabetes Mellitus Patients with Acute Coronary Syndrome: A Meta-analysis. Diabetes Ther 2023; 14:387-399. [PMID: 36542307 PMCID: PMC9943993 DOI: 10.1007/s13300-022-01354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) is often associated with macrovascular complications including cardiovascular diseases (CVDs), resulting in acute coronary syndrome (ACS). Newer potent antiplatelet agents have recently been approved for use in clinical practice. In this analysis, we aimed to systematically compare the cardiovascular outcomes observed with ticagrelor versus clopidogrel in T2DM patients with ACS. METHODS From August to September 2022, electronic databases were searched for publications that compared cardiovascular outcomes observed with ticagrelor versus clopidogrel in patients with T2DM. The statistical analysis was carried out using RevMan 5.4 software. A random effect statistical model was used to analyze the data. Risk ratios (RR) with 95% confidence intervals (CIs) were used to represent the data post analysis. RESULTS A total of 5868 participants with T2DM were included in this analysis, of which 1944 participants were assigned to the ticagrelor group and 3924 participants were assigned to the clopidogrel group. Our analysis showed that ticagrelor was associated with a significantly lower risk of major adverse cardiac events (MACEs) (RR: 0.64, 95% CI: 0.49-0.84; P = 0.001), all-cause mortality (RR: 0.65, 95% CI: 0.51-0.83; P = 0.0004), and cardiac death (RR: 0.60, 95% CI: 0.43-0.84; P = 0.003) in comparison to clopidogrel. However, the risks of repeated revascularization (RR: 1.48, 95% CI: 0.44-4.99; P = 0.53), stent thrombosis (RR: 0.70, 95% CI: 0.18-2.71; P = 0.60), reinfarction (RR: 0.85, 95% CI: 0.58-1.23; P = 0.39), and stroke (RR: 0.56, 95% CI: 0.14-2.21; P = 0.41) were similar. Ticagrelor was associated with a significantly higher risk of minor bleeding (RR: 1.53, 95% CI: 1.07-2.19; P = 0.02), whereas the risk for major bleeding (RR: 1.08, 95% CI: 0.55-2.10; P = 0.82) was not significantly different. CONCLUSIONS In these T2DM patients with ACS, a significantly lower risk of major adverse cardiovascular events including all-cause mortality was observed in the ticagrelor group compared with the clopidogrel group. However, T2DM patients who were assigned to ticagrelor showed a significantly higher minor bleeding risk. Larger clinical trials should be able to confirm these hypotheses.
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Affiliation(s)
- Zhiming Jiang
- Department of Cardiology, The Fourth Hospital of Changsha, Changsha, 410000 Hunan People’s Republic of China
| | - Le Liu
- Department of Cardiology, The Eighth Hospital of Changsha, Changsha, 410001 Hunan People’s Republic of China
| | - Pravesh Kumar Bundhun
- Department of Internal Medicine, Bruno Cheong Hospital, Central Flacq, 40614 Mauritius
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Oh S, Jeong MH, Cho KH, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y. Impact of P2Y12 inhibitors on cardiovascular outcomes of Korean acute myocardial infarction patients with baseline thrombocytopenia. Front Cardiovasc Med 2022; 9:921955. [PMID: 36186989 PMCID: PMC9515375 DOI: 10.3389/fcvm.2022.921955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAntiplatelet therapy is crucial for managing acute myocardial infarction (AMI) and reducing adverse ischemic events after percutaneous coronary intervention (PCI) with drug-eluting stents. However, the ideal P2Y12 inhibitor for patients—particularly East Asians—with AMI and low platelet levels remains unknown. We evaluated the impact of various potencies of P2Y12 receptors on major cardiovascular outcomes of AMI patients with thrombocytopenia in Korea.MethodsWe analyzed the clinical and outcome data of 800 AMI patients with baseline platelet counts <150 × 103/μL who underwent PCI between November 2011 and June 2015. All patient data were obtained from the Korea Acute Myocardial Infarction Registry–National Institutes of Health registry. Subjects were allocated to group A (n = 244; treated with potent P2Y12 inhibitors) or group B (n = 556; treated with clopidogrel). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs).ResultsAt the 3-year follow-up, clinical outcomes appeared better in group A than in Group B. However, after propensity score weighting-adjusted analysis, these findings were statistically attenuated, showing a similar incidence of MACCEs between the two groups.ConclusionsClopidogrel may be reasonable for patients with low platelet counts and is associated with comparable outcomes to potent P2Y12 inhibitors for Korean AMI patients.
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Affiliation(s)
- Seok Oh
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, South Korea
- *Correspondence: Myung Ho Jeong
| | - Kyung Hoon Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, South Korea
| | - Doo Sun Sim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, South Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, South Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, South Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, South Korea
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Chen Y, Tu S, Chen Z, Xia J, Chen B, Chen J, Liang J, Liu X, Tang L. Ticagrelor versus Clopidogrel in Patients with Severe Renal Insufficiency Undergoing PCI for Acute Coronary Syndrome. J Interv Cardiol 2022; 2022:6476777. [PMID: 35966043 PMCID: PMC9357815 DOI: 10.1155/2022/6476777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 07/14/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Current guidelines recommend the use of potent antiplatelet agents in patients undergoing percutaneous coronary intervention (PCI) following an acute coronary syndrome (ACS). However, data about optimal platelet inhibition in severe renal insufficiency patients are scarce. The purpose of this study is to determine if ticagrelor is more effective than clopidogrel in patients with ACS and severe renal insufficiency treated with PCI. METHODS We retrospectively enrolled patients with ACS and severe renal insufficiency (eGFR ≤ 30 ml/min·1.73 m2 or dialysis) who underwent PCI at our hospital between January 2015 and March 2020. We used the adjusted Cox proportional hazards models to analyze the 1-year outcome endpoints, including the primary endpoint (the composite of cardiovascular death, recurrence of MI, or nonfatal ischemic stroke), death from any cause, and bleeding events (Bleeding Academic Research Consortium, BARC criteria). RESULTS A total of 276 patients with ACS and severe renal insufficiency who were treated with PCI with ticagrelor (n = 108) or clopidogrel (n = 168) were included in the study. After adjustment, there was no statistical difference in risk of the primary endpoint (HR, 0.78; 95% CI, 0.46-1.33; P=0.367) and death from any cause (HR, 0.86; 95% CI, 0.38-1.89; P=0.708) in the ticagrelor group against the clopidogrel group. However, the risk of total bleeding was significantly higher in the ticagrelor group (HR, 3.01; 95% CI, 1.81-5.62; P=0.01). Subgroup analysis according to the confounders did not identify any significant subgroup heterogeneity. CONCLUSION Ticagrelor did not improve the major adverse cardiovascular events and all-cause mortality when compared to clopidogrel, but significantly increased the risk of bleeding in Chinese patients with ACS and severe renal insufficiency undergoing PCI.
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Affiliation(s)
- Yunxian Chen
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Shaowen Tu
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Zhixin Chen
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Jue Xia
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Baofeng Chen
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Jinfeng Chen
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Jiarong Liang
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Xiangyang Liu
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
| | - Liangqiu Tang
- Department of Cardiology, Yue Bei People's Hospital, Shantou University Medical College, Shaoguan, China
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Abstract
BACKGROUND The main complications of elevated systemic blood pressure (BP), coronary heart disease, ischaemic stroke, and peripheral vascular disease, are related to thrombosis rather than haemorrhage. Therefore, it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated BP. OBJECTIVES To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with elevated BP, including elevations in systolic or diastolic BP alone or together. To assess the effects of antiplatelet agents on total deaths or major thrombotic events or both in these patients versus placebo or other active treatment. To assess the effects of oral anticoagulants on total deaths or major thromboembolic events or both in these patients versus placebo or other active treatment. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to January 2021: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 12), Ovid MEDLINE (from 1946), and Ovid Embase (from 1974). The World Health Organization International Clinical Trials Registry Platform and the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) were searched for ongoing trials. SELECTION CRITERIA: RCTs in patients with elevated BP were included if they were ≥ 3 months in duration and compared antithrombotic therapy with control or other active treatment. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for inclusion criteria, our prespecified outcomes, and sources of bias. They assessed the risks and benefits of antiplatelet agents and anticoagulants by calculating odds ratios (OR), accompanied by the 95% confidence intervals (CI). They assessed risks of bias and applied GRADE criteria. MAIN RESULTS: Six trials (61,015 patients) met the inclusion criteria and were included in this review. Four trials were primary prevention (41,695 patients; HOT, JPAD, JPPP, and TPT), and two secondary prevention (19,320 patients, CAPRIE and Huynh). Four trials (HOT, JPAD, JPPP, and TPT) were placebo-controlled and two studies (CAPRIE and Huynh) included active comparators. Four studies compared acetylsalicylic acid (ASA) versus placebo and found no evidence of a difference for all-cause mortality (OR 0.97, 95% CI 0.87 to 1.08; 3 studies, 35,794 participants; low-certainty evidence). We found no evidence of a difference for cardiovascular mortality (OR 0.98, 95% CI 0.82 to 1.17; 3 studies, 35,794 participants; low-certainty evidence). ASA reduced the risk of all non-fatal cardiovascular events (OR 0.63, 95% CI 0.45 to 0.87; 1 study (missing data in 3 studies), 2540 participants; low-certainty evidence) and the risk of all cardiovascular events (OR 0.86, 95% CI 0.77 to 0.96; 3 studies, 35,794 participants; low-certainty evidence). ASA increased the risk of major bleeding events (OR 1.77, 95% CI 1.34 to 2.32; 2 studies, 21,330 participants; high-certainty evidence). One study (CAPRIE; ASA versus clopidogrel) included patients diagnosed with hypertension (mean age 62.5 years, 72% males, 95% Caucasians, mean follow-up: 1.91 years). It showed no evidence of a difference for all-cause mortality (OR 1.02, 95% CI 0.91 to 1.15; 1 study, 19,143 participants; high-certainty evidence) and for cardiovascular mortality (OR 1.08, 95% CI 0.94 to 1.26; 1 study, 19,143 participants; high-certainty evidence). ASA probably reduced the risk of non-fatal cardiovascular events (OR 1.10, 95% CI 1.00 to 1.22; 1 study, 19,143 participants; high-certainty evidence) and the risk of all cardiovascular events (OR 1.08, 95% CI 1.00 to 1.17; 1 study, 19,143 participants; high-certainty evidence) when compared to clopidogrel. Clopidogrel increased the risk of major bleeding events when compared to ASA (OR 1.35, 95% CI 1.14 to 1.61; 1 study, 19,143 participants; high-certainty evidence). In one study (Huynh; ASA verus warfarin) patients with unstable angina or non-ST-segment elevation myocardial infarction, with prior coronary artery bypass grafting (CABG) were included (mean age 68 years, 79.8% males, mean follow-up: 1.1 year). There was no evidence of a difference for all-cause mortality (OR 0.98, 95% CI 0.06 to 16.12; 1 study, 91 participants; low-certainty evidence). Cardiovascular mortality, non-fatal cardiovascular events, and all cardiovascular events were not available. There was no evidence of a difference for major bleeding events (OR 0.13, 95% CI 0.01 to 2.60; 1 study, 91 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: There is no evidence that antiplatelet therapy modifies mortality in patients with elevated BP for primary prevention. ASA reduced the risk of cardiovascular events and increased the risk of major bleeding events. Antiplatelet therapy with ASA probably reduces the risk of non-fatal and all cardiovascular events when compared to clopidogrel. Clopidogrel increases the risk of major bleeding events compared to ASA in patients with elevated BP for secondary prevention. There is no evidence that warfarin modifies mortality in patients with elevated BP for secondary prevention. The benefits and harms of the newer drugs glycoprotein IIb/IIIa inhibitors, clopidogrel, prasugrel, ticagrelor, and non-vitamin K antagonist oral anticoagulants for patients with high BP have not been studied in clinical trials. Further RCTs of antithrombotic therapy including newer agents and complete documentation of all benefits and harms are required in patients with elevated BP.
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Affiliation(s)
- Eduard Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Monika Kozieł-Siołkowska
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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Mori H, Mizukami T, Maeda A, Fukui K, Akashi Y, Ako J, Ikari Y, Ebina T, Tamura K, Namiki A, Michishita I, Kimura K, Suzuki H. A Japanese Dose of Prasugrel versus a Standard Dose of Clopidogrel in Patients with Acute Myocardial Infarction from the K-ACTIVE Registry. J Clin Med 2022; 11:jcm11072016. [PMID: 35407624 PMCID: PMC8999969 DOI: 10.3390/jcm11072016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin plus P2Y12 inhibitor is used as a standard therapy for patients with acute myocardial infarction (AMI) treated with drug-eluting stents (DESs). In Japan, clopidogrel was the major P2Y12 inhibitor used for a decade until the new P2Y12 inhibitor, prasugrel, was introduced. Based on clinical studies considering Japanese features, the set dose for prasugrel was reduced to 20 mg as a loading dose (LD) and 3.75 mg as a maintenance dose (MD); these values are 60 and 10 mg, respectively, globally. Despite this dose discrepancy, little real-world clinical data regarding its efficacy and safety exist. METHODS From the K-ACTIVE registry, based on the DAPT regimen, patients were divided into a prasugrel group and a clopidogrel group. The ischemic event was a composite of cardiovascular death, non-fatal MI, and non-fatal stroke. The bleeding event was type 3 or 5 bleeding based on the Bleeding Academic Research Consortium (BARC) criteria. RESULTS Substantially more patients were prescribed prasugrel (n = 2786) than clopidogrel (n = 890). Clopidogrel tended to be selected over prasugrel in older patients with numerous comorbidities. Before adjustments were made, the cumulative incidence of ischemic events at 1 year was significantly greater in the clopidogrel group than in the prasugrel group (p = 0.007), while the cumulative incidence of bleeding events at 1 year was comparable between the groups (p = 0.131). After adjustments were made for the age, sex, body weight, creatine level, type of AMI, history of MI, approach site, oral anticoagulation therapy, presence of multivessel disease, Killip classification, and presence of intra-aortic balloon pumping, both ischemic and bleeding events became comparable between the groups. CONCLUSION A Japanese dose of prasugrel was commonly used in AMI patients in the real-world database. Both the prasugrel and clopidogrel groups showed comparable rates of 1 year ischemic and bleeding events.
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Affiliation(s)
- Hiroyoshi Mori
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama 227-8501, Japan; (T.M.); (A.M.); (H.S.)
- Correspondence: ; Tel.: +81-459711151
| | - Takuya Mizukami
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama 227-8501, Japan; (T.M.); (A.M.); (H.S.)
| | - Atsuo Maeda
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama 227-8501, Japan; (T.M.); (A.M.); (H.S.)
| | - Kazuki Fukui
- Kanagawa Cardiovascular and Respiratory Center, Department of Cardiology, Yokohama 236-0051, Japan;
| | - Yoshihiro Akashi
- Department of Cardiology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan;
| | - Junya Ako
- Department of Cardiology, Kitasato University School of Medicine, Sagamihiara 252-0375, Japan;
| | - Yuji Ikari
- Department of Cardiology, Tokai University School of Medicine, Isehara 259-1193, Japan;
| | - Toshiaki Ebina
- Department of Laboratory Medicine, Yokohama City University Medical Center, Yokohama 232-0024, Japan;
| | - Kouichi Tamura
- Department of Cardiology, Yokohama City University Graduate School of Medicine, Yokohama 236-0004, Japan;
| | - Atsuo Namiki
- Department of Cardiology, Kanto Rosai Hospital, Kawasaki 211-8510, Japan;
| | - Ichiro Michishita
- Department of Cardiology, Yokohama Sakae Kyosai Hospital, Yokohama 247-8581, Japan;
| | - Kazuo Kimura
- Department of Cardiology, Yokohama City University Medical Center, Yokohama 232-0024, Japan;
| | - Hiroshi Suzuki
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama 227-8501, Japan; (T.M.); (A.M.); (H.S.)
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He P, Luo X, Li J, Li Y, Wang X, Huang L, Jin J, Han Y. Clinical Outcome between Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome and Diabetes. Cardiovasc Ther 2021; 2021:5546260. [PMID: 34737792 PMCID: PMC8536459 DOI: 10.1155/2021/5546260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 07/07/2021] [Accepted: 09/11/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The increased thrombotic risk in patients with acute coronary syndrome (ACS) and diabetes highlights the need for adequate antithrombotic protection. We aimed to compare the 6-month clinical outcomes between ticagrelor and clopidogrel in patients with ACS and diabetes. METHODS AND RESULTS The study was a single-center, prospective, randomized, open-label, blinded endpoint, and controlled registry trial. A total of 270 ACS patients with diabetes were randomly assigned in a 1 : 1 ratio to either the ticagrelor group or the clopidogrel group. Follow-up was performed for 6 months, and the data on efficacy outcomes and bleeding events were collected. At 6 months, complete follow-up data were available for 266 (98.5%) of 270 patients, and 4 were lost to follow-up. There was no significant difference in the survival rate of the effective endpoints between the ticagrelor group (n = 133) and the clopidogrel group (n = 133) (HR 0.83, 95% CI 0.44-1.56, p = 0.561), but the incidence of bleeding events in the ticagrelor group was higher than that in the clopidogrel group (HR 1.76, 95% CI 1.00-3.10, p = 0.049). CONCLUSION Ticagrelor did not improve the composite of nonfatal MI, target vessel revascularization, rehospitalization, stroke, and death from any cause; however, it significantly increased the incidence of bleeding events defined by the Bleeding Academic Research Consortium (BARC) criteria in Chinese patients with ACS and diabetes during the 6-month follow-up compared with clopidogrel.
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Affiliation(s)
- Peixun He
- Department of Cardiology, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Xiaolin Luo
- Department of Cardiology, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jiabei Li
- Department of Cardiology, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Lan Huang
- Department of Cardiology, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jun Jin
- Department of Cardiology, The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Sawano M, Spertus JA, Masoudi FA, Rumsfeld JS, Numasawa Y, Inohara T, Kennedy K, Ueda I, Miyata H, Fukuda K, Kohsaka S. Bleeding avoidance strategies and percutaneous coronary intervention outcomes: A 10-year observation from a Japanese Multicenter Registry. Am Heart J 2021; 235:113-124. [PMID: 33472053 DOI: 10.1016/j.ahj.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Bleeding avoidance strategies (BASs) are increasingly adopted for patients undergoing percutaneous coronary intervention (PCI) due to bleeding complications. However, their association with bleeding events outside of Western countries remains unclear. In collaboration with the National Cardiovascular Data Registry (NCDR) CathPCI registry, we aimed to assess the time trend and impact of BAS utilization among Japanese patients. METHODS Our study included 19,656 consecutive PCI patients registered over 10 years. These patients were divided into 4-time frame groups (T1: 2008-2011, T2: 2012-2013, T3: 2014-2015, and T4: 2016-2018). BAS was defined as the use of transradial approach or vascular closure device (VCD) use after transfemoral approach (TFA). Model performance of the NCDR CathPCI bleeding model was evaluated. The degree of bleeding reduction associated with BAS adoption was estimated via multilevel mixed-effects multivariable logistic regression analysis. RESULTS The NCDR CathPCI bleeding risk score demonstrated good discrimination in the Japanese population (C-statistics 0.79-0.81). The BAS adoption rate increased from 43% (T1) to 91% (T4), whereas the crude CathPCI-defined bleeding rate decreased from 10% (T1) to 7% (T4). Adjusted odds ratios for bleeding events were 0.25 (95% confidence interval, 0.14-0.45, P< .001) for those undergoing TFA with VCD in T4 and 0.26 (95% confidence interval 0.20-0.35, P< .001) for transradial approach in T4 compared to patients that received TFA without VCD in T1. CONCLUSIONS BAS use over the studied time frames was associated with lower risk of bleeding complications among Japanese. Nonetheless, observed bleeding rates remained higher compared to the US population.
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Han X, Bai L, Jeong MH, Ahn JH, Hyun DY, Cho KH, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y. Higher Long-Term Mortality in Patients with Non-ST-Elevation Myocardial Infarction than ST-Elevation Myocardial Infarction after Discharge. Yonsei Med J 2021; 62:400-408. [PMID: 33908210 PMCID: PMC8084695 DOI: 10.3349/ymj.2021.62.5.400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/04/2021] [Accepted: 03/09/2021] [Indexed: 01/25/2023] Open
Abstract
PURPOSE This study aimed to compare mortality rates after discharge between the patients with non-ST-elevation myocardial infarction (NSTEMI) and those with ST-elevation myocardial infarction (STEMI), and identify each mortality risk factors in these two types of myocardial infarction. MATERIALS AND METHODS Between 2011 and 2015, 13105 consecutive patients were enrolled in the Korea Acute Myocardial Infarction-National Institute of Health registry (KAMIR-NIH); 12271 patients with acute myocardial infarction met the inclusion criteria and were further stratified into the STEMI (n=5828) and NSTEMI (n=6443) groups. The occurrence of mortality and cardiac mortality at 3 years were compared between groups, and the factors associated with mortality for NSTEMI and STEMI were evaluated. RESULTS The comparison between these two groups and long-term follow-up outcomes showed that the cumulative rates of all-cause and cardiac mortality were higher in the NSTEMI group than in the STEMI group [all-cause mortality: 10.9% vs. 5.8%; hazards ratio (HR), 0.464; 95% confidence interval (CI), 0.359-0.600, p<0.001; cardiac mortality: 6.6% vs. 3.5%, HR, 0.474; 95% CI, 0.344-0.654, p<0.001, respectively). In the NSTEMI group, low left ventricular ejection fraction (LVEF; <40%), no percutaneous coronary intervention (PCI), old age (≥65 years), and low hemoglobin level (<12 g/dL) were identified as risk factors for 3-year mortality. In the STEMI group, old age, low glomerular filtration rate (<60 mL/min/1.73 m²), low LVEF, high heart rate (>100 beats/min), no PCI, and low hemoglobin level were identified as the risk factors for 3-year mortality. CONCLUSION The NSTEMI group had higher mortality compared to the STEMI group during the 3-year clinical follow-up after discharge. Low LVEF and no PCI were the main risk factors for mortality in the NSTEMI group. In contrast, old age and renal dysfunction were the risk factors for long-term mortality in the STEMI group.
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Affiliation(s)
- Xiongyi Han
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
- Department of Cardiology, Yanbian University Hospital, Yanji, China
| | - Liyan Bai
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
- Department of Cardiology, Yanbian University Hospital, Yanji, China
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea.
| | - Joon Ho Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Dae Young Hyun
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Hoon Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Doo Sun Sim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
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Ma X, Sun Y, Cheng Y, Shen H, Gao F, Qi J, Yang L, Wang Z, Shi D, Liu Y, Liu X, Zhou Y. Prognostic impact of the atherogenic index of plasma in type 2 diabetes mellitus patients with acute coronary syndrome undergoing percutaneous coronary intervention. Lipids Health Dis 2020; 19:240. [PMID: 33198752 PMCID: PMC7667811 DOI: 10.1186/s12944-020-01418-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/09/2020] [Indexed: 12/21/2022] Open
Abstract
Background The association of the atherogenic index of plasma (AIP), an emerging lipid index that can predict the risk for cardiovascular disease, with adverse outcomes in type 2 diabetes mellitus (T2DM) patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) has not been determined. Therefore, the aim of this study was to investigate whether the AIP could independently predict adverse cardiovascular events in T2DM patients with ACS undergoing PCI. Methods This study was a retrospective analysis of a single-centre prospective registry involving 826 consecutive T2DM patients who underwent primary or elective PCI for ACS from June 2016 to November 2017. This study ultimately included 798 patients (age, 61 ± 10 years; male, 72.7%). The AIP was calculated as the base 10 logarithm of the ratio of the plasma concentration of triglycerides to high-density lipoprotein-cholesterol (HDL-C). All the patients were divided into 4 groups based on the AIP quartiles. The primary endpoint was a composite of death from any cause, non-fatal spontaneous myocardial infarction (MI), non-fatal ischaemic stroke, and unplanned repeat revascularization. The key secondary endpoint was a composite of cardiovascular death, non-fatal MI, and non-fatal ischaemic stroke. Results During a median follow-up period of 927 days, 198 patients developed at least one event. An unadjusted Kaplan-Meier analysis showed that the incidence of the primary endpoint increased gradually with rising AIP quartiles (log-rank test, P = 0.001). A multivariate Cox proportional hazards analysis revealed that compared with the lowest AIP quartile, the top AIP quartile was associated with significantly increased risk for the primary and key secondary endpoints (hazard ratio [HR]: 2.249, 95% confidence interval [CI]: 1.438 to 3.517, P < 0.001; and HR: 2.571, 95% CI: 1.027 to 6.440, P = 0.044, respectively). Conclusions A higher AIP value on admission was independently and strongly associated with adverse cardiovascular events in T2DM patients with ACS undergoing PCI.
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Affiliation(s)
- Xiaoteng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Yan Sun
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Yujing Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Hua Shen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Fei Gao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Jing Qi
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Lixia Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Zhijian Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Dongmei Shi
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Yuyang Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China
| | - Xiaoli Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China.
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, 100029, China.
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10
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Kim W, Kim JS, Rha SW, Choi BG, Jang WY, Kang DO, Park Y, Choi JY, Roh SY, Na JO, Choi CU, Kim EJ, Park CG, Seo HS, Choi SY, Byun JK, Cha J, Oh DJ, Jeong MH. Cilostazol-based triple versus potent P2Y12 inhibitor-based dual antiplatelet therapy in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Heart Vessels 2020; 35:1181-1192. [PMID: 32270356 DOI: 10.1007/s00380-020-01598-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/27/2020] [Indexed: 11/28/2022]
Abstract
Although potent P2Y12 inhibitor-based dual antiplatelet therapy (DAPT) has replaced clopidogrel-based therapy as the standard treatment in patients with acute myocardial infarction (AMI), there is a concern about the risk of bleeding in East Asian patients. We compared the efficacy and safety of cilostazol-based triple antiplatelet therapy (TAT) with potent P2Y12 inhibitor-based DAPT in Korean patients. A total of 4152 AMI patients who underwent percutaneous coronary intervention (PCI) in the Korea Acute Myocardial Infarction Registry were analyzed retrospectively. Patients were divided into two groups: the TAT group (aspirin + clopidogrel + cilostazol, n = 3161) and the potent DAPT group (aspirin + potent P2Y12 inhibitors [ticagrelor or prasugrel], n = 991). Major clinical outcomes at 30 days and 2 years were compared between the two groups using propensity score matching (PSM) analysis. After PSM (869 pairs), there were no significant differences between the two groups in the incidence of total death, cardiac death, myocardial infarction (MI), target vessel revascularization, stent thrombosis, and stroke at 30 days and 2 years. However, the Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding rates were significantly lower in the TAT group compared with the potent DAPT group at 2 years (6.4% vs. 3.6%, p = 0.006). In Korean AMI patients undergoing PCI, TAT with cilostazol was associated with lower bleeding than the potent P2Y12 inhibitor-based DAPT without increased ischemic risk. These results could provide a rationale for the use of TAT in East Asian AMI patients.
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Affiliation(s)
- Woohyeun Kim
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jin-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea. .,Cardiovascular Intervention Research Institute, Seoul, Republic of Korea.
| | - Byoung Geol Choi
- College of Medicine, Institute of Health Science, Korea University, Seoul, Republic of Korea
| | - Won Young Jang
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Dong Oh Kang
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Yoonjee Park
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jah Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Seung-Young Roh
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Eung Ju Kim
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Se Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jae Kyeong Byun
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jinah Cha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Dong Joo Oh
- Cardiovascular Intervention Research Institute, Seoul, Republic of Korea
| | - Myung Ho Jeong
- Heart Center of Chonnam, National University Hospital, Gwangju, Republic of Korea
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Akita K, Inohara T, Yamaji K, Kohsaka S, Numasawa Y, Ishii H, Amano T, Kadota K, Nakamura M, Maekawa Y. Impact of reduced-dose prasugrel vs. standard-dose clopidogrel on in-hospital outcomes of percutaneous coronary intervention in 62 737 patients with acute coronary syndromes: a nationwide registry study in Japan. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:231-238. [DOI: 10.1093/ehjcvp/pvz056] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/01/2019] [Accepted: 10/02/2019] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
In Japan, reduced-dose prasugrel (loading/maintenance dose, 20/3.75 mg) has been approved for use in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), because of the higher bleeding risk among East Asians. However, its safety in the real-world population has not been investigated. We aimed to evaluate the effectiveness and safety of reduced-dose prasugrel vs. standard-dose clopidogrel in ACS patients undergoing PCI.
Methods and results
Acute coronary syndrome patients who underwent PCI in 2016, who were treated with either reduced-dose prasugrel or standard-dose clopidogrel in addition to aspirin, were identified from the nationwide Japanese PCI registry. The primary outcome was in-hospital mortality following PCI. Secondary outcomes included stent thrombosis and bleeding complication after PCI. Among 62 737 ACS patients who underwent PCI at any of 986 participating centres across Japan (clopidogrel 31.9%; prasugrel 68.1%), we identified 12 016 propensity score-matched pairs (24 032 patients; age 69.4 ± 12.2 years; female 24.9%; ST-elevation myocardial infarction 42.3%). Compared with standard-dose clopidogrel, reduced-dose prasugrel was associated with increased risk of bleeding [odds ratio (OR) 1.65, 95% confidence interval (CI) 1.10–2.51; P = 0.016], but both had similar rates of mortality (OR 1.11, 95% CI 0.89–1.38; P = 0.371) and stent thrombosis (OR 1.29, 95% CI 0.73–2.30; P = 0.387) as well as similar falsification endpoints of cardiac tamponade and emergent operation.
Conclusion
In Japanese ACS patients undergoing PCI, the risk of bleeding is higher when using reduced-dose prasugrel than when using standard-dose clopidogrel, but there is no significant difference in in-hospital mortality and incidence of stent thrombosis between the two antiplatelet regimens.
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Affiliation(s)
- Keitaro Akita
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia V6N 3S9, Canada
| | - Kyohei Yamaji
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu 802-8555, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga 326-0843, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute 480-1195, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki 710-8602, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
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