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Witberg G, Bathish J, Bental T, Leshem-Lev D, Assali A, Kornowski R, Lev E. The effect of cessation of 2nd generation P 2Y 12 inhibitor therapy on platelet reactivity in patients 1 year after acute myocardial infarction. J Thromb Thrombolysis 2018; 46:351-358. [PMID: 29922880 DOI: 10.1007/s11239-018-1701-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To assess the effect of cessation of dual antiplatelet therapy (DAPT) regimens containing 2nd generation P2Y12 inhibitors on platelet reactivity, in patients who completed 12 months of DAPT following an acute myocardial infarction. Clinical data has shown an increased cardiovascular risk in the 90 days following cessation of DAPT. One possible explanation is a transient platelet hyper-reactivity after cessation of treatment. Data from patients treated with 2nd generation P2Y12 inhibitors is scarce. Patients who completed 12 month DAPT with prasugrel/ticagrelor underwent serial assessment of platelet reactivity (on DAPT and 1, 4 and 12 weeks post cessation). The primary outcome was platelet reactivity, expressed as platelet reactivity units (PRU) at each time point. 41 participants were included in this study, (23 ticagrelor, 18 prasugrel). There was no statistically significant differences in baseline characteristics between prasugrel/ticagrelor treated patients . The pattern of platelet reactivity recovery after DAPT cessation differed between the ticagrelor and prasugrel: with ticagrelor, after the initial PRU increase from baseline, the PRU remained stable, while with prasugrel, there was a further increase in PRU between 1 and 4 weeks, with a return to the 1 week level by 12 weeks (p = 0.034 for the time × treatment interaction between ticagrelor and prasugrel). Our results suggest there is a transient platelet hyper-reactivity after cessation of ADP receptor blockers therapy with prasugrel, but not ticagrelor. Further research is required to elucidate the pathophysiologic mechanisms behind these findings and to evaluate potential strategies to prevent or overcome this "rebound" effect.
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Affiliation(s)
- Guy Witberg
- Department of Cardiology, Rabin Medical Center, 100 Jabutinski St, 98100, Petach Tikva, Israel. .,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Jalal Bathish
- Department of Internal Medicine B, Rabin Medical Center, Hasharon Hospital, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamir Bental
- Department of Cardiology, Rabin Medical Center, 100 Jabutinski St, 98100, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dorit Leshem-Lev
- Department of Cardiology, Rabin Medical Center, 100 Jabutinski St, 98100, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abid Assali
- Department of Cardiology, Rabin Medical Center, 100 Jabutinski St, 98100, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, 100 Jabutinski St, 98100, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Lev
- Department of Cardiology, Rabin Medical Center, 100 Jabutinski St, 98100, Petach Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Banerjee S, Angiolillo DJ, Boden WE, Murphy JG, Khalili H, Hasan AA, Harrington RA, Rao SV. Use of Antiplatelet Therapy/DAPT for Post-PCI Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol 2017; 69:1861-1870. [DOI: 10.1016/j.jacc.2017.02.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/21/2017] [Accepted: 02/03/2017] [Indexed: 01/19/2023]
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Santos-Gallego CG. Legacy of blood: does prasugrel inhibit megakaryocytes and do juvenile platelets inherit this inhibition? Haematologica 2016; 100:1103-5. [PMID: 26341522 DOI: 10.3324/haematol.2015.132134] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Carlos G Santos-Gallego
- AtheroThrombosis Research Unit, Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
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Ford I. Coming safely to a stop: a review of platelet activity after cessation of antiplatelet drugs. Ther Adv Drug Saf 2015; 6:141-50. [PMID: 26301068 PMCID: PMC4530348 DOI: 10.1177/2042098615588085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes during percutaneous coronary intervention and after placement of arterial stents. Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed. The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding. Fear of a 'rebound' of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in patients who are stable. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel. Recent randomized controlled trials confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping dual antiplatelet therapy before surgery or in individuals at highest bleeding or thrombotic risk.
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Affiliation(s)
- Isobel Ford
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK
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Baaten CCFMJ, Veenstra LF, Wetzels R, van Geffen JP, Swieringa F, de Witt SM, Henskens YMC, Crijns H, Nylander S, van Giezen JJJ, Heemskerk JWM, van der Meijden PEJ. Gradual increase in thrombogenicity of juvenile platelets formed upon offset of prasugrel medication. Haematologica 2015; 100:1131-8. [PMID: 26113418 DOI: 10.3324/haematol.2014.122457] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 06/22/2015] [Indexed: 12/14/2022] Open
Abstract
In patients with acute coronary syndrome, dual antiplatelet therapy with aspirin and a P2Y12 inhibitor like prasugrel is prescribed for one year. Here, we investigated how the hemostatic function of platelets recovers after discontinuation of prasugrel treatment. Therefore, 16 patients who suffered from ST-elevation myocardial infarction were investigated. Patients were treated with aspirin (100 mg/day, long-term) and stopped taking prasugrel (10 mg/day) after one year. Blood was collected at the last day of prasugrel intake and at 1, 2, 5, 12 and 30 days later. Platelet function in response to ADP was normalized between five and 30 days after treatment cessation and in vitro addition of the reversible P2Y12 receptor antagonist ticagrelor fully suppressed the regained activation response. Discontinuation of prasugrel resulted in the formation of an emerging subpopulation of ADP-responsive platelets, exhibiting high expression of active integrin αIIbβ3. Two different mRNA probes, thiazole orange and the novel 5'Cy5-oligo-dT probe revealed that this subpopulation consisted of juvenile platelets, which progressively contributed to platelet aggregation and thrombus formation under flow. During offset, juvenile platelets were overall more reactive than older platelets. Interestingly, the responsiveness of both juvenile and older platelets increased in time, pointing towards a residual inhibitory effect of prasugrel on the megakaryocyte level. In conclusion, the gradual increase in thrombogenicity after cessation of prasugrel treatment is due to the increased activity of juvenile platelets.
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Affiliation(s)
- Constance C F M J Baaten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Leo F Veenstra
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Rick Wetzels
- Central Diagnostic Laboratory, Maastricht University Medical Centre, The Netherlands
| | - Johanna P van Geffen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Frauke Swieringa
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Susanne M de Witt
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre, The Netherlands
| | - Harry Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | | | | | - Johan W M Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
| | - Paola E J van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, The Netherlands
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Fiedler KA, Mehilli J, Kufner S, Schlichting A, Ibrahim T, Sibbing D, Ott I, Schunkert H, Laugwitz KL, Kastrati A, Schulz S. Randomised, double-blind trial on the value of tapered discontinuation of clopidogrel maintenance therapy after drug-eluting stent implantation. Intracoronary Stenting and Antithrombotic Regimen: CAUTION in Discontinuing Clopidogrel Therapy--ISAR-CAUTION. Thromb Haemost 2014; 111:1041-9. [PMID: 24633406 DOI: 10.1160/th13-11-0900] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/19/2013] [Indexed: 11/05/2022]
Abstract
There is little evidence on the optimal mode of clopidogrel discontinuation. Epidemiological studies observed clustering of thrombotic events after cessation of chronic clopidogrel therapy. The underlying mechanism has been ascribed to transient platelet hyper-reactivity. Gradual tapering of clopidogrel may have the potential to attenuate this phenomenon. The objective of the present study was to assess whether in patients with drug-eluting stents (DES) gradual discontinuation of clopidogrel maintenance therapy is superior to conventional, abrupt discontinuation. Patients with planned discontinuation of chronic clopidogrel therapy after DES implantation were randomised in a double-blinded fashion to either gradual discontinuation (according to a tapering schema over four weeks) or abrupt discontinuation (after continued clopidogrel therapy for additional four weeks). The primary endpoint was the composite of cardiac death, myocardial infarction, stroke, stent thrombosis, major bleeding or rehospitalisation due to an acute coronary syndrome at 90 days. Enrollment of 3,000 patients was planned. The study was stopped prematurely due to slow recruitment after enrollment of 782 patients. At 90 days, nine of 392 patients (2.3%) with tapered cessation reached the primary endpoint compared to five of 390 patients (1.3%) with abrupt cessation (p=0.284). The composite of death or myocardial infarction occurred in three patients with tapered and three patients with abrupt discontinuation (p=0.764). In conclusion, tapered discontinuation of chronic clopidogrel therapy is not superior to abrupt discontinuation regarding the primary endpoint in this study. However, the results must be interpreted in view of the premature termination of the trial and low event rates.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stefanie Schulz
- Stefanie Schulz, MD, ISAResearch Center, Deutsches Herzzentrum München, Lazarettstrasse 36, 80636 Munich, Germany, Tel: +49 89 1218 4578, Fax: +49 89 1218 1539, E-mail:
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Oprea AD, Popescu WM. ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly. J Cardiothorac Vasc Anesth 2013; 27:779-95. [DOI: 10.1053/j.jvca.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 02/02/2023]
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Kristensen SD, Grove EL, Hvas AM. P2Y12 inhibitors in acute coronary syndromes: how do we choose the best drug for our patients? Thromb Haemost 2012; 108:203-5. [PMID: 22739804 DOI: 10.1160/th12-06-0430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 06/25/2012] [Indexed: 11/05/2022]
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Bernlochner I, Morath T, Brown PB, Zhou C, Baker BA, Gupta N, Jakubowski JA, Winters KJ, Schömig A, Kastrati A, Sibbing D. A prospective randomized trial comparing the recovery of platelet function after loading dose administration of prasugrel or clopidogrel. Platelets 2012; 24:15-25. [DOI: 10.3109/09537104.2011.654003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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