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Berry J, Peaudecerf FJ, Masters NA, Neeves KB, Goldstein RE, Harper MT. An "occlusive thrombosis-on-a-chip" microfluidic device for investigating the effect of anti-thrombotic drugs. LAB ON A CHIP 2021; 21:4104-4117. [PMID: 34523623 PMCID: PMC8547327 DOI: 10.1039/d1lc00347j] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/05/2021] [Indexed: 05/03/2023]
Abstract
Cardiovascular disease remains one of the world's leading causes of death. Myocardial infarction (heart attack) is triggered by occlusion of coronary arteries by platelet-rich thrombi (clots). The development of new anti-platelet drugs to prevent myocardial infarction continues to be an active area of research and is dependent on accurately modelling the process of clot formation. Occlusive thrombi can be generated in vivo in a range of species, but these models are limited by variability and lack of relevance to human disease. Although in vitro models using human blood can overcome species-specific differences and improve translatability, many models do not generate occlusive thrombi. In those models that do achieve occlusion, time to occlusion is difficult to measure in an unbiased and objective manner. In this study we developed a simple and robust approach to determine occlusion time of a novel in vitro microfluidic assay. This highlighted the potential for occlusion to occur in thrombosis microfluidic devices through off-site coagulation, obscuring the effect of anti-platelet drugs. We therefore designed a novel occlusive thrombosis-on-a-chip microfluidic device that reliably generates occlusive thrombi at arterial shear rates by quenching downstream coagulation. We further validated our device and methods by using the approved anti-platelet drug, eptifibatide, recording a significant difference in the "time to occlude" in treated devices compared to control conditions. These results demonstrate that this device can be used to monitor the effect of antithrombotic drugs on time to occlude, and, for the first time, delivers this essential data in an unbiased and objective manner.
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Affiliation(s)
- Jess Berry
- Department of Pharmacology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1PD, UK.
| | - François J Peaudecerf
- Department of Civil, Environmental, and Geomatic Engineering, ETH Zürich, 8093 Zürich, Switzerland
| | - Nicole A Masters
- Department of Bioengineering, Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, Hemophilia and Thrombosis Center, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, USA
| | - Keith B Neeves
- Department of Bioengineering, Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, Hemophilia and Thrombosis Center, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, USA
| | - Raymond E Goldstein
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, UK
| | - Matthew T Harper
- Department of Pharmacology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1PD, UK.
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Hemingway H, Feder GS, Fitzpatrick NK, Denaxas S, Shah AD, Timmis AD. Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BackgroundElectronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.ObjectiveTo evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.DesignEpidemiological cohort, health informatics, health economics and ethnographic approaches were used.Setting230 NHS hospitals and 226 general practices in England and Wales.ParticipantsUp to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.Main outcome measuresQuality of care, fatal and non-fatal cardiovascular disease (CVD) events.Data platform and methodsWe created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.ResultsCALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.ConclusionsEmerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.Future workThe vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.Study registrationCALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).
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Affiliation(s)
- Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Gene S Feder
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Natalie K Fitzpatrick
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Anoop D Shah
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Adam D Timmis
- Farr Institute of Health Informatics Research, University College London, London, UK
- Barts Health NHS Trust, London, UK
- Farr Institute of Health Informatics Research, Queen Mary University of London, London, UK
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3
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Angoulvant D, Bejan Angoulvant T, Fauchier L. Dual antiplatelet therapy after acute coronary syndrome: a cardiologist-based optimal decision. BRITISH HEART JOURNAL 2015; 101:832-3. [DOI: 10.1136/heartjnl-2014-307356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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4
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Cayla G, Silvain J, O'Connor SA, Collet JP, Montalescot G. An evidence-based review of current anti-platelet options for STEMI patients. Int J Cardiol 2013; 166:294-303. [DOI: 10.1016/j.ijcard.2012.04.160] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 03/29/2012] [Accepted: 04/14/2012] [Indexed: 10/28/2022]
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Meier P, Timmis A. Almanac 2012: Interventional cardiology. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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6
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Almanac 2012: Interventional cardiology. Rev Port Cardiol 2013. [DOI: 10.1016/j.repc.2013.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Meier P, Timmis A. Almanac 2012: Interventional cardiology. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2013; 83:138-48. [PMID: 23499246 DOI: 10.1016/j.acmx.2013.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 01/16/2013] [Indexed: 11/18/2022] Open
Affiliation(s)
- Pascal Meier
- The Heart Hospital, University College London Hospitals UCLH, London, UK.
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8
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Meier P, Timmis A. Almanac 2012: Interventional cardiology. Egypt Heart J 2013. [DOI: 10.1016/j.ehj.2012.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Jones DA, Andiapen M, Van-Eijl TJA, Webb AJ, Antoniou S, Schilling RJ, Ahluwalia A, Mathur A. The safety and efficacy of intracoronary nitrite infusion during acute myocardial infarction (NITRITE-AMI): study protocol of a randomised controlled trial. BMJ Open 2013; 3:bmjopen-2013-002813. [PMID: 23550096 PMCID: PMC3641434 DOI: 10.1136/bmjopen-2013-002813] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Acute myocardial infarction (AMI) is a major cause of death and disability in the UK and worldwide. Presently, timely and effective reperfusion with primary percutaneous coronary intervention (PPCI) remains the most effective treatment strategy for limiting infarct size, preserving left ventricular ejection fraction (LVEF) and improving clinical outcomes. However, the process of reperfusion can itself induce cardiomyocyte death, known as myocardial reperfusion injury, for which there is currently no effective therapy. Extensive preclinical evidence exists to suggest that sodium nitrite (as a source of endogenous nitric oxide) is an effective therapeutic strategy for preventing myocardial reperfusion injury. The purpose of NITRITE-AMI is to test whether sodium nitrite reduces reperfusion injury and subsequent infarct size in patients undergoing PPCI for MI. METHODS AND DESIGN NITRITE-AMI is a double-blind, randomised, single-centre, placebo-controlled trial to determine whether intracoronary nitrite injection reduces infarct size in patients with myocardial infarction undergoing primary angioplasty. The study will enrol 80 patients presenting with ST-elevation myocardial infarction. Patients will be randomised to receive either a bolus of intracoronary sodium nitrite or placebo (sodium chloride) at the time of PPCI. The primary outcome is infarct size assessed by creatine kinase area under the curve (AUC) over 48 h. Secondary endpoints include troponin T AUC and infarct size, LV dimensions and myocardial salvage index assessed by cardiac MR (CMR), markers of platelet reactivity and inflammation, the safety and tolerability of intracoronary nitrite, and 1 year major adverse cardiac events. ETHICS AND DISSEMINATION The study is approved by the local ethics committee (NRES Committee London West London: 11/LO/1500) and by the Medicines and Healthcare Products Regulatory Agency (MHRA) (EudraCT nr. 2010-022460-12). The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION United Kingdom Clinical Research Network (Study ID 12117), http://clinicaltrials.gov (NCT01584453) and Current Controlled Trials (ISRCTN:38736987).
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Affiliation(s)
- D A Jones
- Centre of Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Unit, William Harvey Research Institute, Queen Mary University, London, UK
- Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - M Andiapen
- Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - T J A Van-Eijl
- Centre of Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Unit, William Harvey Research Institute, Queen Mary University, London, UK
| | - A J Webb
- Centre of Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Unit, William Harvey Research Institute, Queen Mary University, London, UK
| | - S Antoniou
- Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - R J Schilling
- Centre of Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Unit, William Harvey Research Institute, Queen Mary University, London, UK
- Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
| | - A Ahluwalia
- Centre of Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Unit, William Harvey Research Institute, Queen Mary University, London, UK
| | - A Mathur
- Centre of Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Unit, William Harvey Research Institute, Queen Mary University, London, UK
- Department of Cardiology, London Chest Hospital, Barts Health NHS Trust, London, UK
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Abstract
Non-ST elevation (NSTE) myocardial infarction and unstable angina are the most common clinical presentations of acute coronary syndrome (ACS). Platelet activation is central to the pathogenesis of NSTE-ACS and consensus guidelines that advocate early revascularization supported by intensive antiplatelet therapy. This review examines the drugs used concurrently with aspirin as dual antiplatelet therapy in the NSTE-ACS setting. Clopidogrel represented an important therapeutic advance. However, variations in platelet response and a relatively slow onset of action compromise outcomes with clopidogrel. Evidence reviewed in this article shows that in NSTE-ACS patients, ticagrelor and prasugrel are more effective than clopidogrel and are relatively well tolerated, with an acceptable and manageable bleeding risk. The literature suggests several differences between ticagrelor and prasugrel that should allow clinicians to better tailor treatment to the patient. Head-to-head comparisons are now needed to compare directly the risks and benefits of ticagrelor and prasugrel in NSTE-ACS. Further studies also need to address other outstanding issues such as the benefits and risks of prasugrel pre-treatment and to stratify efficacy and tolerability according to diabetes mellitus (DM) and other co-morbidities. In the meantime, the issues discussed in this review should enhance clinicians' ability to optimize and individualize NSTE-ACS treatment, thereby further reducing the morbidity and mortality associated with this common cardiovascular condition.
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Affiliation(s)
- G Cayla
- Institut de Cardiologie, Bureau 236, Pitié-Salpêtrière University Hospital, 47-83, Bld de l'Hôpital, 75013 Paris, France
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Knight C, Timmis AD. Almanac 2011: Acute coronary syndromes. The national society journals present selected research that has driven recent advances in clinical cardiology. Egypt Heart J 2012. [DOI: 10.1016/j.ehj.2012.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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12
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Packard KA, Campbell JA, Knezevich JT, Davis EM. Emerging Antiplatelet Therapy for Coronary Artery Disease and Acute Coronary Syndrome. Pharmacotherapy 2012; 32:244-73. [DOI: 10.1002/j.1875-9114.2012.01021.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Jon T. Knezevich
- Department of Pharmacy Practice; School of Pharmacy and Health Professions
| | - Estella M. Davis
- Department of Pharmacy Practice; School of Pharmacy and Health Professions
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Almanac 2011: Acute coronary syndromes. The national society journals present selected research that has driven recent advances in clinical cardiology. Rev Port Cardiol 2012; 31:179-88. [DOI: 10.1016/j.repc.2011.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 10/28/2011] [Indexed: 11/21/2022] Open
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Knight C, Timmis AD. Almanac 2011: Acute coronary syndromes. The national society journals present selected research that has driven recent advances in clinical cardiology. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Gayle JA, Kaye AD, Kaye AM, Shah R. Anticoagulants: newer ones, mechanisms, and perioperative updates. Anesthesiol Clin 2010; 28:667-679. [PMID: 21074744 DOI: 10.1016/j.anclin.2010.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
With a growing number of new anticoagulant/antiplatelet agents being developed, it is likely that an increasing number of patients taking these drugs will present for surgery and other procedures. A familiarity with mechanisms of action and drug interactions helps to maintain optimal patient safety in the perioperative period. Furthermore, it is crucial for anesthesiologists to remain current on recommendations regarding discontinuation or need to continue the newer anticoagulants/antiplatelet drugs in patients presenting for surgery and/or regional anesthesia. Further studies are needed for monitoring of many of these newer agents and to identify antidotes.
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Affiliation(s)
- Julie A Gayle
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA.
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Biondi-Zoccai G, Lotrionte M, Agostoni P, Abbate A, Romagnoli E, Sangiorgi G, Angiolillo DJ, Valgimigli M, Testa L, Gaita F, Sheiban I. Adjusted indirect comparison meta-analysis of prasugrel versus ticagrelor for patients with acute coronary syndromes. Int J Cardiol 2010; 150:325-31. [PMID: 20828843 DOI: 10.1016/j.ijcard.2010.08.035] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 05/30/2010] [Accepted: 08/07/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Clopidogrel is beneficial after ACS. Recent data suggest the superiority of prasugrel or ticagrelor compared with clopidogrel. However, there is no comparison of prasugrel vs. ticagrelor. We performed an adjusted indirect meta-analysis comparing prasugrel vs. ticagrelor for acute coronary syndromes (ACSs). METHODS Randomized trials were searched in PubMed. The primary end-point was the composite of death, myocardial infarction (MI) or stroke. Odds ratios (OR) were computed (95% confidence intervals). RESULTS Three trial (32,893) patients were included. Overall, either prasugrel or ticagrelor appeared significantly superior to clopidogrel for the 12-month risk of death, MI or stroke (OR=0.83 [0.77-0.89], p<0.001), death (OR=0.83 [0.74-0.93], p=0.001), MI (OR=0.79 [0.73-0.86], p<0.001), and stent thrombosis (OR=0.61 [0.51-0.74], p<0.001), without any significant difference in stroke or major bleeding (both p>0.05), despite more frequent drug discontinuation (OR=1.12 [1.05-1.19], p<0.001). Head-to-head comparison of prasugrel vs. ticagrelor showed no significant differences in overall death, MI, stroke, or their composite (all p>0.05). Prasugrel was associated with a significantly lower risk of stent thrombosis (OR=0.64 [0.43-0.93], p=0.020). Ticagrelor was associated with a significantly lower risk of any major bleeding (OR=1.43 [1.10-1.85], p=0.007), and major bleeding associated with bypass grafting (OR=4.30 [1.73-10.6], p=0.002). However, the more clinically relevant risk of major bleeding not related to bypass surgery was similar with either prasugrel or ticagrelor (OR=1.06 [0.77-1.45], p=0.34). CONCLUSIONS Prasugrel and ticagrelor are superior to clopidogrel for ACS. Head-to-head comparison suggests similar efficacy and safety of prasugrel and ticagrelor, but prasugrel appears more protective from stent thrombosis, while causing more bleedings.
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Affiliation(s)
- Giuseppe Biondi-Zoccai
- Division of Cardiology, University of Turin, San Giovanni Battista "Molinette" Hospital, Turin, Italy.
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