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Van Oosterom N, Barras M, Cottrell N, Bird R. Platelet function assays for the diagnosis of aspirin resistance. Platelets 2021; 33:329-338. [PMID: 34166171 DOI: 10.1080/09537104.2021.1942816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Aspirin, an antiplatelet drug, is commonly used at low doses for numerous indications, including prophylaxis of cardiovascular, neurovascular, and venous thromboembolic events. Due to review articles suggesting that aspirin resistance may result in poorer outcomes, interest in assessing platelet function is increasing. Despite this, platelet function tests are rarely used as part of routine clinical practice and therefore, a basic understanding of these tests may be lacking. Although aspirin resistance can be categorized as clinical or laboratory resistance, determining laboratory resistance is the only way to determine resistance before treatment failure occurs. Therefore, knowledge of platelet assays to determine aspirin resistance is of importance. The following review aims to provide a framework for clinicians to understand the main principles of platelet function tests. This includes comparison of the most frequently used platelet assays to diagnose aspirin resistance, including the basic mechanism, methodology, reference ranges, inter-assay comparison, and their respective clinical considerations when using.
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Affiliation(s)
- Nameer Van Oosterom
- School of Pharmacy, University of Queensland, Brisbane, Australia.,Pharmacy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Michael Barras
- School of Pharmacy, University of Queensland, Brisbane, Australia.,Pharmacy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Robert Bird
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Australia
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2
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Blomqvist LRF, Strandell AM, Jeppsson A, Hellgren MSE. Arachidonic acid-induced platelet aggregation and acetylsalicylic acid treatment during pregnancy in women with recurrent miscarriage, a post hoc study. Platelets 2021; 33:278-284. [PMID: 33646930 DOI: 10.1080/09537104.2021.1883573] [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: 10/22/2022]
Abstract
In this post hoc study, arachidonic acid (AA)-induced platelet aggregation during pregnancy with and without acetylsalicylic acid (ASA) treatment was studied in 323 women with unexplained recurrent first-trimester miscarriage and in 59 healthy women with normal pregnancies. All women had normal AA-induced platelet aggregation in the non-pregnant state. Women with recurrent miscarriage were treated with 75 mg ASA or placebo daily. AA-induced platelet aggregation was measured with multiple electrode impedance aggregometry and presented in units (U), where 1 U = 10 aggregation units x minutes. There were no significant differences in platelet aggregation between placebo-treated women with recurrent miscarriage and healthy women. The mean differences were-0.7 (95%CI; -7.0; 5.6) U in the non-pregnant state, 3.8 (95%CI; -4.6; 12.2) U during the late first trimester and 1.7 (95%CI; -6.7; 10.3) U and 4.1 (95%CI; -3.9; 12.0) U during the early and late third trimester, respectively. ASA reduced platelet aggregation by median -84.0% (Q1; Q3; -89.8; -76.3), -79.9% (-84.7; -69.2) and -75.7% (-83.5; -49.5), respectively, during pregnancy. The degree of inhibition by ASA decreased during the third trimester (p < .0001). There were two (1.9%) complete non-responders to ASA and 32.1% with a partial response. The rate of subsequent miscarriage was not affected by ASA, which did not seem to influence the rate of early miscarriage if treatment was initiated when a viable pregnancy was detectable by ultrasound.
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Affiliation(s)
- Lennart R F Blomqvist
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborg Hospital, Borås, Sweden
| | - Annika M Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margareta S E Hellgren
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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3
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Wiśniewski A. Multifactorial Background for a Low Biological Response to Antiplatelet Agents Used in Stroke Prevention. ACTA ACUST UNITED AC 2021; 57:medicina57010059. [PMID: 33435185 PMCID: PMC7827369 DOI: 10.3390/medicina57010059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/27/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
Effective platelet inhibition is the main goal of the antiplatelet therapy recommended as a standard treatment in the secondary prevention of non-embolic ischemic stroke. Acetylsalicylic acid (aspirin) and clopidogrel are commonly used for this purpose worldwide. A low biological response to antiplatelet agents is a phenomenon that significantly reduces the therapeutic and protective properties of the therapy. The mechanisms leading to high on-treatment platelet reactivity are still unclear and remain multifactorial. The aim of the current review is to establish the background of resistance to antiplatelet agents commonly used in the secondary prevention of ischemic stroke and to explain the possible mechanisms. The most important factors influencing the incidence of a low biological response were demonstrated. The similarities and the differences in resistance to both drugs are emphasized, which may facilitate the selection of the appropriate antiplatelet agent in relation to specific clinical conditions and comorbidities. Despite the lack of indications for the routine assessment of platelet reactivity in stroke subjects, this should be performed in selected patients from the high-risk group. Increasing the detectability of low antiaggregant responders, in light of its negative impact on the prognosis and clinical outcomes, can contribute to a more individualized approach and modification of the antiplatelet therapy to maximize the therapeutic effect in the secondary prevention of stroke.
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Affiliation(s)
- Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Skłodowskiej 9 Street, 85-094 Bydgoszcz, Poland
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Tuteja S, Ferguson JF. Gut Microbiome and Response to Cardiovascular Drugs. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 12:421-429. [PMID: 31462078 DOI: 10.1161/circgen.119.002314] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The gut microbiome is emerging as an important contributor to both cardiovascular disease risk and metabolism of xenobiotics. Alterations in the intestinal microbiota are associated with atherosclerosis, dyslipidemia, hypertension, and heart failure. The microbiota have the ability to metabolize medications, which can results in altered drug pharmacokinetics and pharmacodynamics or formation of toxic metabolites which can interfere with drug response. Early evidence suggests that the gut microbiome modulates response to statins and antihypertensive medications. In this review, we will highlight mechanisms by which the gut microbiome facilitates the biotransformation of drugs and impacts pharmacological efficacy. A better understanding of the complex interactions of the gut microbiome, host factors, and response to medications will be important for the development of novel precision therapeutics for targeting CVD.
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Affiliation(s)
- Sony Tuteja
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (S.T.)
| | - Jane F Ferguson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (J.F.F.)
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Racca C, van Diemen JJK, Fuijkschot WW, Spit K, Bonten TN, Numans ME, van der Bom JG, Smulders YM, Thijs A. Aspirin intake in the morning is associated with suboptimal platelet inhibition, as measured by serum Thromboxane B2, during infarct-prone early-morning hours. Platelets 2018; 30:871-877. [DOI: 10.1080/09537104.2018.1528347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Cati Racca
- Department of Internal Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
| | | | - Wessel Willem Fuijkschot
- Department of Internal Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
| | - Karlinde Spit
- Department of Internal Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
| | - Tobias Nicolaas Bonten
- Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mattijs Everard Numans
- Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna Gerarda van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- JJ van Rood Center for Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
| | - Yvo Michiel Smulders
- Department of Internal Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam University Medical Center, VU University, Amsterdam, The Netherlands
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Saito Y, Okada S, Ogawa H, Soejima H, Sakuma M, Nakayama M, Doi N, Jinnouchi H, Waki M, Masuda I, Morimoto T. Low-Dose Aspirin for Primary Prevention of Cardiovascular Events in Patients With Type 2 Diabetes Mellitus. Circulation 2017; 135:659-670. [DOI: 10.1161/circulationaha.116.025760] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/04/2016] [Indexed: 01/19/2023]
Abstract
Background:
The long-term efficacy and safety of low-dose aspirin for primary prevention of cardiovascular events in patients with type 2 diabetes mellitus are still inconclusive.
Methods:
The JPAD trial (Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes) was a randomized, open-label, standard care–controlled trial examining whether low-dose aspirin affected cardiovascular events in 2539 Japanese patients with type 2 diabetes mellitus and without preexisting cardiovascular disease. Patients were randomly allocated to receive aspirin (81 or 100 mg daily; aspirin group) or no aspirin (no-aspirin group) in the JPAD trial. After that trial ended in 2008, we followed up with the patients until 2015, with no attempt to change the previously assigned therapy. Primary end points were cardiovascular events, including sudden death, fatal or nonfatal coronary artery disease, fatal or nonfatal stroke, and peripheral vascular disease. For the safety analysis, hemorrhagic events, consisting of gastrointestinal bleeding, hemorrhagic stroke, and bleeding from any other sites, were also analyzed. The primary analysis was conducted for cardiovascular events among patients who retained their original allocation (a per-protocol cohort). Analyses on an intention-to-treat cohort were conducted for hemorrhagic events and statistical sensitivity.
Results:
The median follow-up period was 10.3 years; 1621 patients (64%) were followed up throughout the study; and 2160 patients (85%) retained their original allocation. Low-dose aspirin did not reduce cardiovascular events in the per-protocol cohort (hazard ratio, 1.14; 95% confidence interval, 0.91–1.42). Multivariable Cox proportional hazard model adjusted for age, sex, glycemic control, kidney function, smoking status, hypertension, and dyslipidemia showed similar results (hazard ratio, 1.04; 95% confidence interval, 0.83–1.30), with no heterogeneity of efficacy in subgroup analyses stratified by each of these factors (all interaction
P
>0.05). Sensitivity analyses on the intention-to-treat cohort yielded consistent results (hazard ratio, 1.01; 95% confidence interval, 0.82–1.25). Gastrointestinal bleeding occurred in 25 patients (2%) in the aspirin group and 12 (0.9%) in the no-aspirin group (
P
=0.03), and the incidence of hemorrhagic stroke was not different between groups.
Conclusions:
Low-dose aspirin did not affect the risk for cardiovascular events but increased risk for gastrointestinal bleeding in patients with type 2 diabetes mellitus in a primary prevention setting.
Clinical Trial Registration:
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00110448.
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Affiliation(s)
- Yoshihiko Saito
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Sadanori Okada
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Hisao Ogawa
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Hirofumi Soejima
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Mio Sakuma
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Masafumi Nakayama
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Naofumi Doi
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Hideaki Jinnouchi
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Masako Waki
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Izuru Masuda
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
| | - Takeshi Morimoto
- From First Department of Internal Medicine (Y.S., S.O.) and Department of Diabetology (S.O.), Nara Medical University, Kashihara, Japan; National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (H.O.); Department of Cardiovascular Medicine, Graduate School of Medical Science, Kumamoto University, Cyuo-ku, Japan (H.S.); Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (M.S., T.M.); Nakayama Cardiovascular Clinic, Amakusa, Kumamoto, Japan (M.N.); Department of
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Kuliha M, Roubec M, Goldírová A, Hurtíková E, Jonszta T, Procházka V, Gumulec J, Herzig R, Školoudík D. Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study. J Atheroscler Thromb 2016; 23:839-47. [PMID: 26783048 DOI: 10.5551/jat.31799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIM New ischemic lesions in the brain can be detected in approximately 50% of patients undergoing carotid artery stenting (CAS). We wished to discover the laboratory-based predictors of new infarctions in the brain after CAS. METHODS All consecutive patients with internal carotid artery stenosis of ≥70% with indication for CAS were enrolled in a prospective study for 16 months. All patients used dual antiplatelet therapy for ≥7 days before CAS. Neurologic examination and magnetic resonance imaging (MRI) of the brain were undertaken before and at 24 h after CAS. Samples of venous blood were collected at <24 h before CAS for the evaluation of hematology, reticulocytes, coagulation markers (PT, APTT, Fbg, Clauss), vWF antigen, PAI-1 activity, PAI-1 polymorphism 4G/5G, and the multiplate (aspirin and clopidogrel) resistance test. Blood samples for the assessment of anti-Xa activity were collected during CAS. Differences in the values of laboratory markers between patients with and without new ischemic lesions of the brain on control MRI were evaluated. RESULTS The cohort comprised 81 patients (53 males; mean age, 67.3±7.2 years). New ischemic infarctions in the brain on control MRI were found in 46 (56.8%) patients. Three of seven patients with resistance to aspirin or clopidogrel had a new ischemic infarction in the brain. No significant differences for particular markers were found between patients with and without an ischemic lesion in the brain. CONCLUSION A high risk of a new ischemic infarction in the brain was detected in patients undergoing CAS, but a laboratory-based predictor of such an infarction could not be identified.
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Affiliation(s)
- Martin Kuliha
- Department of Neurology, Comprehensive Stroke Center, University Hospital Ostrava
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Abstract
Stroke recurrence is common in the early period after a cerebral ischemic event. Treatment with an antiplatelet agent is recommended to reduce recurrent stroke and death in patients with a non-cardioembolic ischemic stroke and transient ischemic attack. Compared to monotherapy, dual antiplatelet therapy has more robust inhibition of platelet activation but a higher risk of systemic bleeding and intracranial hemorrhage. Randomized controlled trials and meta-analyses suggest that short-term use of dual antiplatelet treatment initiated early after ischemic stroke and TIA reduces the risk of recurrent stroke and major vascular events without significantly increasing the hemorrhagic complication rates, particularly in those with large-vessel disease, while long-term dual antiplatelet treatment increases the risk of systemic and intracranial hemorrhage over time, offsetting any potential benefit. Until further data becomes available, clinicians should carefully assess this risk and benefit in each case and continually reevaluate the need for prolonged dual antiplatelet therapy.
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Affiliation(s)
- Negar Asdaghi
- University of Miami Miller School of Medicine, 1120 NW 14th Street, 13th floor, Miami, FL, 33136, USA,
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Dretzke J, Riley RD, Lordkipanidzé M, Jowett S, O'Donnell J, Ensor J, Moloney E, Price M, Raichand S, Hodgkinson J, Bayliss S, Fitzmaurice D, Moore D. The prognostic utility of tests of platelet function for the detection of 'aspirin resistance' in patients with established cardiovascular or cerebrovascular disease: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-366. [PMID: 25984731 DOI: 10.3310/hta19370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The use of aspirin is well established for secondary prevention of cardiovascular disease. However, a proportion of patients suffer repeat cardiovascular events despite being prescribed aspirin treatment. It is uncertain whether or not this is due to an inherent inability of aspirin to sufficiently modify platelet activity. This report aims to investigate whether or not insufficient platelet function inhibition by aspirin ('aspirin resistance'), as defined using platelet function tests (PFTs), is linked to the occurrence of adverse clinical outcomes, and further, whether or not patients at risk of future adverse clinical events can be identified through PFTs. OBJECTIVES To review systematically the clinical effectiveness and cost-effectiveness evidence regarding the association between PFT designation of 'aspirin resistance' and the risk of adverse clinical outcome(s) in patients prescribed aspirin therapy. To undertake exploratory model-based cost-effectiveness analysis on the use of PFTs. DATA SOURCES Bibliographic databases (e.g. MEDLINE from inception and EMBASE from 1980), conference proceedings and ongoing trial registries up to April 2012. METHODS Standard systematic review methods were used for identifying clinical and cost studies. A risk-of-bias assessment tool was adapted from checklists for prognostic and diagnostic studies. (Un)adjusted odds and hazard ratios for the association between 'aspirin resistance', for different PFTs, and clinical outcomes are presented; however, heterogeneity between studies precluded pooling of results. A speculative economic model of a PFT and change of therapy strategy was developed. RESULTS One hundred and eight relevant studies using a variety of PFTs, 58 in patients on aspirin monotherapy, were analysed in detail. Results indicated that some PFTs may have some prognostic utility, i.e. a trend for more clinical events to be associated with groups classified as 'aspirin resistant'. Methodological and clinical heterogeneity prevented a quantitative summary of prognostic effect. Study-level effect sizes were generally small and absolute outcome risk was not substantially different between 'aspirin resistant' and 'aspirin sensitive' designations. No studies on the cost-effectiveness of PFTs for 'aspirin resistance' were identified. Based on assumptions of PFTs being able to accurately identify patients at high risk of clinical events and such patients benefiting from treatment modification, the economic model found that a test-treat strategy was likely to be cost-effective. However, neither assumption is currently evidence based. LIMITATIONS Poor or incomplete reporting of studies suggests a potentially large volume of inaccessible data. Analyses were confined to studies on patients prescribed aspirin as sole antiplatelet therapy at the time of PFT. Clinical and methodological heterogeneity across studies precluded meta-analysis. Given the lack of robust data the economic modelling was speculative. CONCLUSIONS Although evidence indicates that some PFTs may have some prognostic value, methodological and clinical heterogeneity between studies and different approaches to analyses create confusion and inconsistency in prognostic results, and prevented a quantitative summary of their prognostic effect. Protocol-driven and adequately powered primary studies are needed, using standardised methods of measurements to evaluate the prognostic ability of each test in the same population(s), and ideally presenting individual patient data. For any PFT to inform individual risk prediction, it will likely need to be considered in combination with other prognostic factors, within a prognostic model. STUDY REGISTRATION This study is registered as PROSPERO 2012:CRD42012002151. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Janine Dretzke
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Richard D Riley
- Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | | | - Susan Jowett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Jennifer O'Donnell
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Joie Ensor
- Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, UK
| | - Eoin Moloney
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Malcolm Price
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Smriti Raichand
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - James Hodgkinson
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Susan Bayliss
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - David Fitzmaurice
- Primary Care Clinical Sciences, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - David Moore
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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Yang Y, Lewis JP, Hulot JS, Scott SA. The pharmacogenetic control of antiplatelet response: candidate genes and CYP2C19. Expert Opin Drug Metab Toxicol 2015; 11:1599-617. [PMID: 26173871 DOI: 10.1517/17425255.2015.1068757] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Aspirin, clopidogrel, prasugrel and ticagrelor are antiplatelet agents for the prevention of ischemic events in patients with acute coronary syndromes (ACS), percutaneous coronary intervention (PCI) and other indications. Variability in response is observed to different degrees with these agents, which can translate to increased risks for adverse cardiovascular events. As such, potential pharmacogenetic determinants of antiplatelet pharmacokinetics, pharmacodynamics and clinical outcomes have been actively studied. AREAS COVERED This article provides an overview of the available antiplatelet pharmacogenetics literature. Evidence supporting the significance of candidate genes and their potential influence on antiplatelet response and clinical outcomes are summarized and evaluated. Additional focus is directed at CYP2C19 and clopidogrel response, including the availability of clinical testing and genotype-directed antiplatelet therapy. EXPERT OPINION The reported aspirin response candidate genes have not been adequately replicated and few candidate genes have thus far been implicated in prasugrel or ticagrelor response. However, abundant data support the clinical validity of CYP2C19 and clopidogrel response variability among ACS/PCI patients. Although limited prospective trial data are available to support the utility of routine CYP2C19 testing, the increased risks for reduced clopidogrel efficacy among ACS/PCI patients that carry CYP2C19 loss-of-function alleles should be considered when genotype results are available.
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Affiliation(s)
- Yao Yang
- a 1 Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences , New York, NY, USA +1 212 241 3780 ; +1 212 241 0139 ;
| | - Joshua P Lewis
- b 2 University of Maryland School of Medicine, Division of Endocrinology, Diabetes and Nutrition, and Program for Personalized and Genomic Medicine , Baltimore, MD, USA
| | - Jean-Sébastien Hulot
- c 3 Icahn School of Medicine at Mount Sinai, Cardiovascular Research Center , New York, NY, USA.,d 4 Sorbonne Universités, UPMC Univ Paris 06, INSERM , UMR_S 1166 ICAN, F-75005 Paris, France
| | - Stuart A Scott
- a 1 Icahn School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences , New York, NY, USA +1 212 241 3780 ; +1 212 241 0139 ;
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Beitelshees AL, Voora D, Lewis JP. Personalized antiplatelet and anticoagulation therapy: applications and significance of pharmacogenomics. Pharmgenomics Pers Med 2015; 8:43-61. [PMID: 25897256 PMCID: PMC4397717 DOI: 10.2147/pgpm.s52900] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In recent years, substantial effort has been made to better understand the influence of genetic factors on the efficacy and safety of numerous medications. These investigations suggest that the use of pharmacogenetic data to inform physician decision-making has great potential to enhance patient care by reducing on-treatment clinical events, adverse drug reactions, and health care-related costs. In fact, integration of such information into the clinical setting may be particularly applicable for antiplatelet and anticoagulation therapeutics, given the increasing body of evidence implicating genetic variation in variable drug response. In this review, we summarize currently available pharmacogenetic information for the most commonly used antiplatelet (ie, clopidogrel and aspirin) and anticoagulation (ie, warfarin) medications. Furthermore, we highlight the currently known role of genetic variability in response to next-generation antiplatelet (prasugrel and ticagrelor) and anticoagulant (dabigatran) agents. While compelling evidence suggests that genetic variants are important determinants of antiplatelet and anticoagulation therapy response, significant barriers to clinical implementation of pharmacogenetic testing exist and are described herein. In addition, we briefly discuss development of new diagnostic targets and therapeutic strategies as well as implications for enhanced patient care. In conclusion, pharmacogenetic testing can provide important information to assist clinicians with prescribing the most personalized and effective antiplatelet and anticoagulation therapy. However, several factors may limit its usefulness and should be considered.
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Affiliation(s)
- Amber L Beitelshees
- Program for Personalized and Genomic Medicine and Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deepak Voora
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke School of Medicine, Durham, NC, USA
| | - Joshua P Lewis
- Program for Personalized and Genomic Medicine and Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
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13
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Castilla-Guerra L, Navas-Alcántara M, Fernández-Moreno M. Aspirin resistant patients with recent ischemic stroke. Rev Clin Esp 2014. [DOI: 10.1016/j.rceng.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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14
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Forood A, Malekpour-Afshar R, Sarnevesht J. Effect of opium addiction on aspirin resistance in stable angina pectoris. ADDICTION & HEALTH 2014; 6:7-13. [PMID: 25140212 PMCID: PMC4137439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 11/01/2013] [Indexed: 11/04/2022]
Abstract
BACKGROUND The rate of cardiovascular diseases in developing countries is approximately 60% and it is still has an increasing trend. The clinical effectiveness of aspirin in preventing cardiovascular events has been well proven. Although aspirin is an effective and inexpensive drug, its consumption is not equally beneficial for all patients. Many factors can be affective on the efficacy of antiplatelet drugs such as aspirin. METHODS This study was carried out on 260 patients who had stable angina pectoris and coronary artery disease was approved by coronary angiography. Based on opium addiction, the patients were divided into two groups. Opium addiction was diagnosed base on Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. The mid-stream morning urinary sample were collected for measuring the urinary 11-dehydroxy thromboxane B2 level (UTXB2). Urinary level of UTXB2 was considered as an aspirin resistance index. FINDINGS The mean age of patients was 57.3 ± 8.9; and 44.6% of them were females. The aspirin resistance rate was 41.5%. Significant difference in aspirin resistance was observed between the opium addicts and non-addicts. (51.5% vs. 31.5%) (P = 0.001). The effects of confounding variables such as diabetes, hypertension, and hyperlipidemia were eliminated by regression logistic multivariable analysis. CONCLUSION The prevalence of aspirin resistance in patients with stable angina pectoris was 41.5%. The prevalence of aspirin resistance in patients with stable angina pectoris who had opium addiction was significantly higher them non-addicts.
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Affiliation(s)
- Afsaneh Forood
- Assistant Professor, Department of Cardiology AND Physiology Research Center, Kerman University of Medical Sciences, Kerman, Iran,Correspondence to: Afsaneh Forood MD,
| | - Reza Malekpour-Afshar
- Associate Professor, Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Jamshid Sarnevesht
- Resident, Department of Cardiology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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15
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Aspirin resistant patients with recent ischemic stroke. Rev Clin Esp 2013; 214:145-9. [PMID: 24211052 DOI: 10.1016/j.rce.2013.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 09/24/2013] [Accepted: 10/02/2013] [Indexed: 11/20/2022]
Abstract
Some patients with a recent ischemic stroke who are being treated with aspirin as an antiaggregant suffer a new ischemic stroke. These patients (15-25%) have been called unresponsive to aspirin or aspirin resistant. The aspirin-resistant patients have a four-time greater risk of suffering a stroke. Furthermore, these strokes are generally more severe, with increased infarct volume and greater risk of recurrence. There is currently no ideal laboratory test to detect the resistance to the antiaggregant effect of aspirin. The study of resistance to aspirin would only be indicated in selected cases. In these patients, one should first rule out any "pseudo-resistance" to aspirin (lack of compliance, concomitant treatments that interfere with the action of the aspirin).
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16
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The contribution of platelet glycoproteins (GPIa C807T and GPIba C-5T) and cyclooxygenase 2 (COX-2G-765C) polymorphisms to platelet response in patients treated with aspirin. Gene 2013; 526:118-21. [DOI: 10.1016/j.gene.2013.04.083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/20/2013] [Accepted: 04/29/2013] [Indexed: 11/20/2022]
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17
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Fisher RG, Teitel ER, Yee AT, Chuang AZ. Evaluation of the Effectiveness of the AggreGuide A-100 in Measuring Platelet Aggregation in Individuals Taking a High or Low Dose of Aspirin. Lab Med 2013. [DOI: 10.1309/lmjf9wk85yaaaeyv] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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18
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Gorelick PB, Farooq MU. Advances in our understanding of "resistance" to antiplatelet agents for prevention of ischemic stroke. Stroke Res Treat 2013; 2013:727842. [PMID: 23936730 PMCID: PMC3725785 DOI: 10.1155/2013/727842] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/27/2013] [Indexed: 01/10/2023] Open
Abstract
We review the role of aspirin and clopidogrel for prevention of ischemic stroke and explore the concept of antiplatelet therapy resistance both from a laboratory and clinical perspective and genetic polymorphisms that might influence platelet reactivity with clopidogrel administration. Debates have raged over the years about the application of platelet function tests in clinical practice. We conclude that platelet function testing is not indicated in routine clinical practice. This recommendation is supported by clinical guideline statements, a lack of a global platelet function measure, and limitations of current platelet function test methods as applied in practice. We discuss a recently hypothesized hierarchy of patient characteristics in relation to which patients are most likely to benefit from platelet function studies based on acuity (i.e., risk) of cardiovascular disease. A focus of antiplatelet therapy administration should include emphasis on compliance/adherence and in the example of aspirin, use of well-absorbed forms of aspirin and avoidance of drugs that may interact with aspirin to inhibit its mechanism of action (e.g., certain nonsteroidal anti-inflammatory drugs).
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Affiliation(s)
- Philip B. Gorelick
- Hauenstein Neuroscience Center, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
- Department of Translational Science and Molecular Medicine, Michigan State University College of Human Medicine, 333 Bostwick Avenue NE, Grand Rapids, MI 49503, USA
| | - Muhammad U. Farooq
- Hauenstein Neuroscience Center, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
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19
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Sharma V, Kaul S, Al-Hazzani A, Alshatwi AA, Jyothy A, Munshi A. Association of COX-2 rs20417 with aspirin resistance. J Thromb Thrombolysis 2013; 35:95-9. [PMID: 22763923 DOI: 10.1007/s11239-012-0777-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aspirin is the most commonly used antiplatelet drug for treatment of a serious vascular event, most notably stroke and myocardial infarction. However, despite the demonstrated benefit of aspirin, significant fraction of aspirin-treated patients may be resistant to the antiplatelet effects of the drug. The possible mechanisms of aspirin resistance (AR) are multifactorial. A genetic basis for AR has been suggested to exist. Therefore, the present study was taken up to investigate the role of -765G/C polymorphism (rs20417) in the cyclooxygenase-2 (COX-2) gene with AR in stroke patients. Four hundred and fifty stroke patients and four hundred and forty age and sex matched healthy controls were involved in the study. Baseline clinical data were collected and follow-up telephone interviews were conducted with patients at 3 months post event to determine stroke outcome using Modified Rankin Scale. Blood samples were collected and genotypes determined by polymerase chain reaction-restriction digestion technique. The association between the genotypes and outcome was evaluated by stepwise multiple logistic regression analysis. The COX-2 CC and GC genotype showed a significant association with bad outcome. Therefore, the carriers of C allele of COX-2 -765G/C polymorphism are more prone to AR in comparison with non-carriers. These results support a potential role of -765G/C COX-2 gene polymorphism with AR in ischemic stroke patients.
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Affiliation(s)
- Vandana Sharma
- Department of Molecular Biology, Institute of Genetics and Hospital for Genetic Diseases, Osmania University, Begumpet, Hyderabad, 500016, India
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20
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Grinshtein YI, Kosinova AA, Grinshtein IY. ASPIRIN RESISTANCE CANDIDATE GENES AND THEIR ASSOCIATION WITH THE RISK OF CARDIOVASCULAR EVENTS. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2013. [DOI: 10.15829/1728-8800-2013-1-67-72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The review presents the current literature evidence on the most likely genetic polymorphisms of aspirin resistance, such as polymorphisms of cyclooxygenase, glycoproteins GP Ib/IIIa, GP Ibα, GP VI, and adenosine diphosphate receptors P2Y1 and P2Y12. The authors discuss the prevalence of these polymorphisms in laboratory and clinical aspirin resistance, as well as their association with the risk of cardiovascular events during aspirin treatment.
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Affiliation(s)
- Yu. I. Grinshtein
- Prof. V.F. Voyno-Yasenetskyi Krasnoyarsk State Medical University, Krasnoyarsk
| | - A. A. Kosinova
- Prof. V.F. Voyno-Yasenetskyi Krasnoyarsk State Medical University, Krasnoyarsk
| | - I. Yu. Grinshtein
- Prof. V.F. Voyno-Yasenetskyi Krasnoyarsk State Medical University, Krasnoyarsk
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21
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Abdullah WZ, Bakar SA, Zain WSWM, Yusof Z, Mustaffa R, Hassan R. Aspirin Effects on Platelets Using Whole Blood Tested by Platelet Aggregometry: A Comparative Study for Test Validation in a Clinical Hemostasis Laboratory. Lab Med 2013. [DOI: 10.1309/lm13ur8vgqtncbvq] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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22
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Oxley TJ, Dowling RJ, Mitchell PJ, Davis S, Yan B. Antiplatelet resistance and thromboembolic complications in neurointerventional procedures. Front Neurol 2011; 2:83. [PMID: 22363312 PMCID: PMC3277275 DOI: 10.3389/fneur.2011.00083] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 11/30/2011] [Indexed: 12/04/2022] Open
Abstract
Antiplatelet resistance is emerging as a significant factor in effective secondary stroke prevention. Prevalence of aspirin and clopidogrel resistance is dependent upon laboratory test and remains contentious. Large studies in cardiovascular disease populations have demonstrated worse ischemic outcomes in patients with antiplatelet resistance, particularly in patients with coronary stents. Thromboembolism is a complication of neurointerventional procedures that leads to stroke. Stroke rates related to aneurysm coiling range from 2 to 10% and may be higher when considering silent ischemia. Stroke associated with carotid stenting is a major cause of morbidity. Antiplatelet use in the periprocedure setting varies among different centers. No guidelines exist for use of antiplatelet regimens in neurointerventional procedures. Incidence of stroke in patients post procedure may be partly explained by resistance to antiplatelet agents. Further research is required to establish the incidence of stroke in patients with antiplatelet resistance undergoing neurointerventional procedures.
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Affiliation(s)
- Thomas J. Oxley
- Department of Neurology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Richard J. Dowling
- Department of Radiology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Peter J. Mitchell
- Department of Radiology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Stephen Davis
- Department of Neurology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Bernard Yan
- Department of Neurology, The Royal Melbourne HospitalMelbourne, VIC, Australia
- Department of Radiology, The Royal Melbourne HospitalMelbourne, VIC, Australia
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23
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Attività piastrinica residua e fallimento clinico della profilassi antitrombotica nell’attacco ischemico cerebrale acuto. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s13631-011-0024-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Castro HC, Abreu PA, Geraldo RB, Martins RCA, dos Santos R, Loureiro NIV, Cabral LM, Rodrigues CR. Looking at the proteases from a simple perspective. J Mol Recognit 2011; 24:165-81. [PMID: 21360607 DOI: 10.1002/jmr.1091] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Proteases have received enormous interest from the research and medical communities because of their significant roles in several human diseases. Some examples include the involvement of thrombin in thrombosis, HIV-1 protease in Acquired Immune Deficiency Syndrome, cruzain in Trypanosoma cruzi infection, and membrane-type 1 matrix metalloproteinase in tumor invasion and metastasis. Many efforts has been undertaken to design effective inhibitors featuring potent inhibitory activity, specificity, and metabolic stability to those proteases involved in such pathologies. Protease inhibitors usually target the active site, but some of them act by other inhibitory mechanisms. The understanding of the structure-function relationships of proteases and inhibitors has an impact on new inhibitor drugs designing. In this paper, the structures of four proteases (thrombin, HIV-protease, cruzain, and a matrix metalloproteinase) are briefly reviewed, and used as examples of the importance of proteases for the development of new treatment strategies, leading to a longer and healthier life.
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Affiliation(s)
- Helena C Castro
- LABioMol, Departamento de Biologia Celular e Molecular, Instituto de Biologia, Universidade Federal Fluminense, Rio de Janeiro, 24001-970, Brazil.
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25
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Okada S, Morimoto T, Ogawa H, Kanauchi M, Nakayama M, Uemura S, Doi N, Jinnouchi H, Waki M, Soejima H, Sakuma M, Saito Y. Differential effect of low-dose aspirin for primary prevention of atherosclerotic events in diabetes management: a subanalysis of the JPAD trial. Diabetes Care 2011; 34:1277-83. [PMID: 21515838 PMCID: PMC3114321 DOI: 10.2337/dc10-2451] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Recent reports showed that low-dose aspirin was ineffective in the primary prevention of cardiovascular events in diabetic patients overall. We hypothesized that low-dose aspirin would be beneficial in patients receiving insulin therapy, as a high-risk group. RESEARCH DESIGN AND METHODS This study is a subanalysis of the Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes (JPAD) trial-a randomized, controlled, open-label trial. We randomly assigned 2,539 patients with type 2 diabetes and no previous cardiovascular disease to the low-dose aspirin group (81 or 100 mg daily) or to the no-aspirin group. The median follow-up period was 4.4 years. We investigated the effect of low-dose aspirin on preventing atherosclerotic events in groups receiving different diabetes management. RESULTS At baseline, 326 patients were treated with insulin, 1,750 with oral hypoglycemic agents (OHAs), and 463 with diet alone. The insulin group had the longest history of diabetes, the worst glycemic control, and the highest prevalence of diabetic microangiopathies. The diet-alone group had the opposite characteristics. The incidence of atherosclerotic events was 26.6, 14.6, and 10.4 cases per 1,000 person-years in the insulin, OHA, and diet-alone groups, respectively. In the insulin and OHA groups, low-dose aspirin did not affect atherosclerotic events (insulin: hazard ratio [HR] 1.19 [95% CI 0.60-2.40]; OHA: HR 0.84 [0.57-1.24]). In the diet-alone group, low-dose aspirin significantly reduced atherosclerotic events, despite the lowest event rates (HR 0.21 [0.05-0.64]). CONCLUSIONS Low-dose aspirin reduced atherosclerotic events predominantly in the diet-alone group and not in the insulin or OHA groups.
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Affiliation(s)
- Sadanori Okada
- First Department of Internal Medicine, Nara Medical University, Shijo-cho, Kashihara, Nara, Japan
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Abstract
Although the exact prevalence of antiplatelet resistance in ischemic stroke is not known, estimates about the two most widely used antiplatelet agents - aspirin and clopidogrel - suggest that the resistance rate is high, irrespective of the definition used and parameters measured. Inadequate antiplatelet responsiveness correlates with an increased risk of recurrent ischemic vascular events in patients with stroke and acute coronary syndrome. It is not currently known whether tailoring antiplatelet therapy based on platelet function test results translates into a more effective strategy to prevent secondary vascular events after stroke. Large-scale clinical trials using a universally accepted definition and standardized measurement techniques for antiplatelet resistance are needed to demonstrate whether a 'platelet-function test-guided antiplatelet treatment' strategy translates into improved stroke care. This article gives an overview of the clinical importance of laboratory antiplatelet resistance, describes the challenges for platelet-function test-guided antiplatelet treatment and discusses practical issues about the management of patients with aspirin and/or clopidogrel resistance.
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Affiliation(s)
| | | | - Hakan Ay
- Stroke Service, Department of Neurology, AA Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, CNY-149-2301, Boston, MA 02129, USA
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27
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Affiliation(s)
- Mark J Alberts
- Department of Neurology, Northwestern University Feinberg School of Medicine, and the Stroke Program, Northwestern Memorial Hospital, Chicago, Ill, USA.
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