1
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Rasu RS, Phadnis MA, Xavier C, Dai J, Hunt SL, Jain N. P2Y12 Inhibitors Refill Gap Predicts Death in Medicare Beneficiaries on Chronic Dialysis. Kidney Int Rep 2024; 9:2125-2133. [PMID: 39081724 PMCID: PMC11284433 DOI: 10.1016/j.ekir.2024.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 04/09/2024] [Accepted: 04/25/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Oral P2Y12 inhibitors (P2Y12-I) are commonly used antiplatelet drugs in patients with end-stage kidney disease (ESKD) on chronic dialysis. Although gaps in prescription refills are quite common in patients with ESKD, it remains unclear whether P2Y12-I prescription refill patterns are associated with adverse clinical outcomes. Methods We used the United States Renal Data System (USRDS) registry for patients with ESKD to capture new P2Y12-I prescriptions from 2011 to 2015. The primary exposure was prescription refill patterns and the primary outcome was all-cause death. Results Among the 31,243 patients with new P2Y12-I prescription, median age was 64 years; 54% were male; and 39% were Caucasian, 37% African American, and 18% Hispanic. We observed 3 P2Y12-I refill patterns as follows: continuous users (45.1%), noncontinuous users (3.6%), and users with ≥30 days refill gap (51.4%). Prescription refill pattern with ≥30 days refill gap (vs. continuous use) was associated with all-cause death (adjusted hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.13-1.23). Age and race were the most important risk factors associated with prescription refill pattern. African Americans (vs. Caucasians) were more likely to demonstrate ≥30 days refill gap, (adjusted odds ratio [OR]: 1.43; 95% CI: 1.36-1.51). In addition, younger patients (vs. older) were more likely to demonstrate ≥30 day refill gap (adjusted OR/decade: 0.9; 95% CI: 0.89-0.92). Conclusion Nonadherence to P2Y12-I prescriptions is quite common, and disproportionately affects minorities. Younger individuals with ESKD are independently associated with a higher risk of death. The odds of having a refill gap are decreasing for older patients who are more compliant than younger patients. Future studies should investigate whether phenotyping subgroups of patients with ESKD based on prescription refill patterns can help in improving adverse clinical outcomes.
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Affiliation(s)
- Rafia S. Rasu
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences, Fort Worth, Texas, USA
| | - Milind A. Phadnis
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Christy Xavier
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences, Fort Worth, Texas, USA
| | - Junqiang Dai
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Suzanne L. Hunt
- Department of Biostatistics and Data Science, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Nishank Jain
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas, USA
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2
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Mathew RO, Sidhu MS, Rihal CS, Lennon R, El-Hajjar M, Yager N, Lyubarova R, Abdul-Nour K, Weitz S, O'Cochlain DF, Murthy V, Levisay J, Marzo K, Graham J, Dzavik V, So D, Goodman S, Rosenberg YD, Pereira N, Farkouh ME. Safety and Efficacy of CYP2C19 Genotype-Guided Escalation of P2Y 12 Inhibitor Therapy After Percutaneous Coronary Intervention in Chronic Kidney Disease: a Post Hoc Analysis of the TAILOR-PCI Study. Cardiovasc Drugs Ther 2024; 38:447-457. [PMID: 36445624 PMCID: PMC10225474 DOI: 10.1007/s10557-022-07392-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Chronic kidney disease (CKD) is a risk factor for ischemic and bleeding events with dual antiplatelet therapy after percutaneous coronary intervention (PCI). Whether the presence of CYP2C19 loss of function (LOF) alleles modifies this risk, and whether a genotype-guided (GG) escalation of P2Y12 inhibitor therapy post PCI is safe in this population is unclear. METHODS This was a post hoc analysis of randomized patients in TAILOR PCI. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR) threshold of < 60 ml/min/1.73 m2 for CKD (n = 539) and non-CKD (n = 4276). The aggregate of cardiovascular death, stroke, myocardial infarction, stent thrombosis, and severe recurrent coronary ischemia at 12-months post-PCI was assessed as the primary endpoint. Secondary endpoint was major or minor bleeding. RESULTS Mean (standard deviation) eGFR among patients with CKD was 49.5 (8.4) ml/min/1.72 m2. Among all patients, there was no significant interaction between randomized strategy and CKD status for any endpoint. Among LOF carriers, the interaction between randomized strategy and CKD status on composite ischemic outcome was not significant (p = 0.2). GG strategy was not associated with an increased risk of bleeding in either CKD group. CONCLUSIONS In this exploratory analysis, escalation of P2Y12 inhibitor therapy following a GG strategy did not reduce the primary outcome in CKD. However, P2Y12 inhibitor escalation following a GG strategy was not associated with increased bleeding risk in CKD. Larger studies in CKD are needed. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01742117?term=TAILOR-PCI&draw=2&rank=1 . NCT01742117.
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Affiliation(s)
- Roy O Mathew
- Department of Medicine, Loma Linda VA Health Care System, 11201 Benton Street, Loma Linda, CA, 92357, USA.
| | - Mandeep S Sidhu
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA.
| | | | - Ryan Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Mohammed El-Hajjar
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Neil Yager
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Radmila Lyubarova
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | | | - Steven Weitz
- Cardiology Associates of Schenectady, Schenectady, NY, USA
| | | | - Vishakantha Murthy
- Department of Endocrine and Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Justin Levisay
- Department of Medicine, North Shore University Health System, Evanston, IL, USA
| | - Kevin Marzo
- Department of Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - John Graham
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Vlad Dzavik
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Derek So
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Shaun Goodman
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | | | | | - Michael E Farkouh
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
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3
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Numasawa Y. Impact of Platelet Reactivity on Ischemic and Bleeding Events After Percutaneous Coronary Intervention - A Long-Term Perspective. Circ J 2022; 86:1350-1351. [PMID: 35650117 DOI: 10.1253/circj.cj-22-0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital
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4
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Mangiacapra F, Paolucci L, Viscusi MM, Mangiacapra R, Ferraro PM, Nusca A, Melfi R, De Luca L, Gabrielli D, Ussia GP, Grigioni F. Prevalence and clinical impact of high platelet reactivity in patients with chronic kidney disease treated with percutaneous coronary intervention: An updated systematic review and meta‐analysis. Catheter Cardiovasc Interv 2022; 99:1086-1094. [DOI: 10.1002/ccd.30071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/17/2021] [Accepted: 12/25/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Fabio Mangiacapra
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
| | - Luca Paolucci
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
| | - Michele M. Viscusi
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
| | - Roberto Mangiacapra
- U.O.C. Nefrologia Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
- Università Cattolica del Sacro Cuore Rome Italy
| | - Pietro M. Ferraro
- U.O.C. Nefrologia Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
- Università Cattolica del Sacro Cuore Rome Italy
| | - Annunziata Nusca
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
| | - Rosetta Melfi
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
| | | | | | - Gian P. Ussia
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
| | - Francesco Grigioni
- Unit of Cardiovascular Science, Department of Medicine Campus Bio‐Medico University Rome Italy
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5
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Baaten CC, Schröer JR, Floege J, Marx N, Jankowski J, Berger M, Noels H. Platelet Abnormalities in CKD and Their Implications for Antiplatelet Therapy. Clin J Am Soc Nephrol 2022; 17:155-170. [PMID: 34750169 PMCID: PMC8763166 DOI: 10.2215/cjn.04100321] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with CKD display a significantly higher risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hyporeactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. In this study, we summarize the knowledge on CKD-induced aberrations in hemostasis, with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation, and red blood cell count in CKD may contribute to altered hemostasis in these patients who are high risk. Furthermore, with patients with CKD commonly receiving antiplatelet therapy to prevent secondary atherothrombotic complications, we discuss antiplatelet treatment strategies and their risk versus benefit in terms of thrombosis prevention, bleeding, and clinical outcome depending on CKD stage. This reveals a careful consideration of benefits versus risks of antiplatelet therapy in patients with CKD, balancing thrombotic versus bleeding risk. Nonetheless, despite antiplatelet therapy, patients with CKD remain at high cardiovascular risk. Thus, deep insights into altered platelet activity in CKD and underlying mechanisms are important for the optimization and development of current and novel antiplatelet treatment strategies, specifically tailored to these patients who are high risk. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and antiplatelet therapy in patients with CKD.
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Affiliation(s)
- Constance C.F.M.J. Baaten
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jonas R. Schröer
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Joachim Jankowski
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Martin Berger
- Department of Internal Medicine I, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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6
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Ilardi F, Gargiulo G, Paolillo R, Ferrone M, Cimino S, Giugliano G, Schiattarella GG, Verde N, Stabile E, Perrino C, Cirillo P, Coscioni E, Morisco C, Esposito G. Impact of chronic kidney disease on platelet aggregation in patients with acute coronary syndrome. J Cardiovasc Med (Hagerstown) 2021; 21:660-666. [PMID: 32520854 DOI: 10.2459/jcm.0000000000000981] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS Chronic kidney disease (CKD) is associated with increased thrombotic events and seems to influence platelet reactivity. Conflicting results have been published on platelet response in CKD patients with stable coronary artery disease. The aim of our study was to investigate the impact of CKD on platelet aggregation in acute coronary syndrome (ACS) patients receiving dual antiplatelet therapy, included the more potent P2Y12 inhibitors. METHODS We enrolled 206 patients with ACS, divided in two groups, according to the presence or the absence of moderate/severe CKD. Platelet aggregation was performed with light transmission aggregometry and results are expressed as percentage of maximum platelet aggregation. High residual platelet reactivity (HRPR) was defined as maximum platelet aggregation more than 59%. RESULTS Patients with CKD [estimate glomerular filtration rate (eGFR) < 60 ml/min/1.73 m, n = 28] were prevalent older, diabetic, had previous coronary revascularization. In these patients, platelet aggregation was significantly higher than in those with eGFR ≥ 60 ml/min/1.73 m (ADP 10 μmol/l: 28.46 ± 26.19 vs. 16.64 ± 12.79, P < 0.001; ADP 20 μmol/l: 30.07 ± 25.89 vs. 17.46 ± 12.82, P < 0.001). HRPR was observed in 4.4% of patients, with higher prevalence in those with eGFR less than 60 ml/min/1.73 m [21.4 vs. 1.7%, P < 0.001, odds ratio (OR) [95% confidence interval (CI)] = 15.91 (3.71-68.17), P < 0.001]. At multivariate analysis, after correction for baseline confounders, eGFR [adjusted OR (95% CI) = 0.95 (0.91-0.98), P = 0.007], together with the use of clopidogrel [adjusted OR (95% CI) = 23.59 (4.01-138.82), P < 0.001], emerged as determinants of HRPR. CONCLUSION In patients with ACS receiving dual antiplatelet therapy, CKD is associated with an increasing ADP-induced platelet aggregation and higher prevalence of HRPR, which is mainly correlated to clopidogrel use.
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Affiliation(s)
- Federica Ilardi
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples.,Mediterranea Cardiocentro, Naples
| | - Giuseppe Gargiulo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Roberta Paolillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Marco Ferrone
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Sara Cimino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Giugliano
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Gabriele G Schiattarella
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples.,Department of Internal Medicine (Cardiology), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicola Verde
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Cinzia Perrino
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Enrico Coscioni
- Department of Heart Surgery, San Giovanni di Dio e Ruggi d'Aragona Hospital, Salerno, Italy
| | - Carmine Morisco
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples.,Mediterranea Cardiocentro, Naples
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7
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Mangiacapra F, Sticchi A, Bressi E, Mangiacapra R, Viscusi MM, Colaiori I, Ricottini E, Cavallari I, Spoto S, Ussia GP, Ferraro PM, Grigioni F. Impact of Chronic Kidney Disease and Platelet Reactivity on Clinical Outcomes Following Percutaneous Coronary Intervention. J Cardiovasc Transl Res 2021; 14:1085-1092. [PMID: 33851372 DOI: 10.1007/s12265-021-10126-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
We investigated the interaction between chronic kidney disease (CKD) and high platelet reactivity (HPR) in determining long-term clinical outcomes following elective PCI for stable coronary artery disease (CAD). A total of 500 patients treated with aspirin and clopidogrel were divided based on the presence of CKD (defined as glomerular filtration rate of < 60 ml/min/1.73 m2) and HPR (defined as a P2Y12 reaction unit value ≥ 240 at VerifyNow assay). Primary endpoint was the occurrence of major adverse clinical events (MACE) at 5 years. Patients with both CKD and HPR showed the highest estimates of MACE (25.6%, p = 0.005), all-cause death (17.9%, p = 0.004), and cardiac death (7.7%, p = 0.004). The combination of CKD and HPR was an independent predictor of MACE (HR 3.12, 95% CI 1.46-6.68, p = 0.003). In conclusion, the combination of CKD and HPR identifies a cohort of patients with the highest risk of MACE at 5 years.
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Affiliation(s)
- Fabio Mangiacapra
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy.
| | - Alessandro Sticchi
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Edoardo Bressi
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Roberto Mangiacapra
- U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Michele Mattia Viscusi
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Iginio Colaiori
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Elisabetta Ricottini
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Ilaria Cavallari
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Silvia Spoto
- Unit of Diagnostic and Therapeutic Medicine, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Gian Paolo Ussia
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Pietro Manuel Ferraro
- U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Francesco Grigioni
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
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8
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Kim JM, Kim JS, Kim HO, Lee SR, Rhew JH, Woo JS, Cho JH, Jeong KH, Kim W. Platelet activity with hemoglobin level in patients with hemodialysis: Prospective study. Medicine (Baltimore) 2020; 99:e19336. [PMID: 32150071 PMCID: PMC7478496 DOI: 10.1097/md.0000000000019336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND VerifyNow (VN; Accumetrics, San Diego, CA) P2Y12 reaction unit (PRU) has an inverse relation with hemoglobin level (Hb). Chronic kidney disease (CKD) is associated with low response to clopidogrel and low Hb. Our aim is to investigate the relation between PRU and Hb, and to assess whether Hb directly affects PRU or not in patients with CKD undergoing hemodialysis (HD). METHODS We analyzed the relation between PRU and Hb in 43 HD patients and compared it with a control group of 127 patients with normal renal function. Both groups underwent percutaneous coronary intervention for stable coronary artery disease. We also compared PRU between the 2 groups considering Hb as a confounding factor. RESULTS In the control group, Hb and PRU showed a significant inverse correlation (correlation coefficient r = -0.340; P < .001), but not in the HD group (correlation coefficient r = -0.099; P = .53). PRU was higher in the HD group than the control group after adjusting for the influence of Hb (299.2 [95% confidence interval: 278.4-316.7] vs 248.7 [95% confidence interval: 227.7-269.0]; P < .001), even after propensity score matching (299.2 [95% confidence interval: 278.4-316.7] vs 241.7 [95% confidence interval: 221.8-262.2]; P < .001). CONCLUSIONS PRU was higher regardless of lower Hb in CKD on HD patients than normal renal function patients. Therefore, Hb was not crucial factor to decide PRU in CKD on HD patients in this study.
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Affiliation(s)
- Jae Min Kim
- Division of Cardiology, Department of Internal Medicine, St. Carollo General Hospital, Suncheon-si
| | | | - Hyung Oh Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - So Ra Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - Jae Hwan Rhew
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - Jong Shin Woo
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - Jang Hyun Cho
- Division of Cardiology, Department of Internal Medicine, St. Carollo General Hospital, Suncheon-si
| | | | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
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9
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Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines. Kidney Int 2019; 97:266-278. [PMID: 31866114 DOI: 10.1016/j.kint.2019.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/06/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.
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10
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Li G, Zhang Y, Zhu Z, Du J. Evaluation of platelet distribution width in hypertension with hyperhomocysteinemia. Clin Exp Hypertens 2019; 42:61-66. [PMID: 30689431 DOI: 10.1080/10641963.2019.1571600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An increased platelet distribution width (PDW) value has been found in various cardiovascular diseases. The objective of this study was to evaluate the association between the PDW and hypertension with hyperhomocysteinemia in an elderly cohort. We performed a cross-sectional analysis among 2,685 elderly individuals who underwent hematological testing and blood pressure assessment. Individuals were divided according to the PDW quartiles. An unconditional multiple logistic regression analysis was used to determine the association between PDW and hypertension with hyperhomocysteinemia, after adjustments for gender, age, drinking status, creatinine levels, glucose levels, uric acid levels, triglyceride levels, platelet counts and body mass index. Homocysteine was observed to steadily and remarkably increase in the PDW quartiles. The PDW values of the hypertension with hyperhomocysteinemia group were significantly greater than the PDW values in the hypertension without hyperhomocysteinemia group or the normotension group. The PDW levels were associated with hypertension and hyperhomocysteinemia independently of the previously mentioned risk factors, and the odds ratio of the hypertension with hyperhomocysteinemia group was steadily and remarkably increased, by as much as two-fold, in the fourth quartile vs. the first quartile. In this elderly population-based cohort, elevated PDW levels were independently associated with hypertension and hyperhomocysteinemia, which may indicate that hypertension and hyperhomocysteinemia can induce platelet activation.
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Affiliation(s)
- Gang Li
- Department of Laboratory of Clinical Chemistry and Hematology, Zhenhai Lianhua Hospital, Ningbo, Zhejiang, China
| | - Yanyan Zhang
- Department of Laboratory of Clinical Chemistry and Hematology, Zhenhai Lianhua Hospital, Ningbo, Zhejiang, China
| | - Zhongwei Zhu
- Department of Internal Medicine, Zhenhai Lianhua Hospital, Ningbo, Zhejiang, China
| | - Juan Du
- Department of Internal Medicine, Zhenhai Lianhua Hospital, Ningbo, Zhejiang, China
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11
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Laboratory Monitoring of Antiplatelet Therapy. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00036-9] [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]
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12
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Zhu P, Tang XF, Xu JJ, Song Y, Liu R, Zhang Y, Gao L, Gao Z, Chen J, Yang YJ, Gao RL, Xu B, Yuan JQ. Platelet reactivity in patients with chronic kidney disease undergoing percutaneous coronary intervention. Platelets 2018; 30:901-907. [PMID: 30518271 DOI: 10.1080/09537104.2018.1549319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study aimed to evaluate the platelet reactivity in real-world patients with different chronic kidney disease (CKD) stages after percutaneous coronary intervention (PCI), and to examine whether high residual platelet reactivity (HRPR) is associated with higher incidence of adverse cardiovascular events in a 2-year follow up. A total of 10 724 consecutive patients receiving DAPT with aspirin and clopidogrel after PCI throughout 2013 were enrolled. We applied modified thromboelastography (mTEG) in 6745 patients. Kaplan-Meier analysis and Cox proportional regression analysis were applied to illustrate end points for patients. The prevalence of HRPR for adenosine diphosphate (ADP) was higher in patients with CKD3-5 than patients with CKD1-2 (47.0% vs. 37.3%, p = 0.002), but not for arachidonic acid (AA). No significant difference was observed for MACCE between patients with or without HRPR for ADP (HR 1.004, 95%CI: 0.864-1.167, p = 0.954). Patients with HRPR for ADP was associated with less bleeding events than patients without HRPR for ADP (HR 0.795, 95%CI: 0.643-0.982, p = 0.034). In this large cohort of real-world patients after PCI, the deterioration of renal function was linked to HRPR for ADP. HRPR was not associated with MACCE in patients with CKD in a 2-year follow up. Bleeding risks were significantly lower in PCI patients with versus without HRPR for ADP.
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Affiliation(s)
- Pei Zhu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Xiao-Fang Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jing-Jing Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ying Song
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ru Liu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yin Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Lijian Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Zhan Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jue Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yue-Jin Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Run-Lin Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Bo Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jin-Qing Yuan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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13
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Bonello L, Angiolillo DJ, Aradi D, Sibbing D. P2Y
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-ADP Receptor Blockade in Chronic Kidney Disease Patients With Acute Coronary Syndromes. Circulation 2018; 138:1582-1596. [DOI: 10.1161/circulationaha.118.032078] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Laurent Bonello
- Aix-Marseille Université, INSERM UMR-S 1076, Vascular Research Center of Marseille, Marseille, France (L.B.)
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Daniel Aradi
- Heart Center Balatonfüred and Semmelweis University Budapest, Hungary (D.A.)
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Germany (D.S.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (D.S.)
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14
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Mathew RO, Gosmanova EO, Sidhu MS. Targeting Cardiovascular Disease in Patients with Chronic Kidney Disease: Is Primary Prevention with Aspirin Ready for Prime Time? : Editorial to: "Aspirin for Primary Prevention of Cardiovascular Disease and Renal Disease Progression in Chronic Kidney Disease Patients: A Multicenter Randomized Clinical Trial (AASER Study)" by M. Goicoechea et al. Cardiovasc Drugs Ther 2018; 32:241-243. [PMID: 29923131 DOI: 10.1007/s10557-018-6803-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Roy O Mathew
- Department of Medicine, Division of Nephrology, William Jennings Bryan Dorn VAMC, Columbia, SC, USA
| | - Elvira O Gosmanova
- Nephrology Section, Stratton VA Medical Center and Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Albany Medical Center and Department of Medicine, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA.
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15
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Edfors R, Sahlén A, Szummer K, Renlund H, Evans M, Carrero JJ, Spaak J, James SK, Lagerqvist B, Varenhorst C, Jernberg T. Outcomes in patients treated with ticagrelor versus clopidogrel after acute myocardial infarction stratified by renal function. Heart 2018; 104:1575-1582. [PMID: 29574413 DOI: 10.1136/heartjnl-2017-312436] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/15/2018] [Accepted: 02/03/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES We aimed to analyse outcomes of ticagrelor and clopidogrel stratified by estimated glomerular filtration rate (eGFR) in a large unselected cohort of patients with acute myocardial infarction (MI). METHODS We used follow-up data in MI survivors discharged on ticagrelor or clopidogrel enrolled in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry. The association between ticagrelor versus clopidogrel and the primary composite outcome of death, MI or stroke and the secondary outcome rehospitalisation with bleeding diagnosis at 1 year, was studied using adjusted Cox proportional hazards models, stratifying after eGFR levels. RESULTS In total, 45 206 patients with MI discharged on clopidogrel (n=33 472) or ticagrelor (n=11 734) were included. The unadjusted 1-year event rate for the composite endpoint of death, MI or stroke was 7.0%, 18.0% and 48.0% for ticagrelor treatment and 11.0%, 33.0% and 64.0% for clopidogrel treatment in patients with eGFR>60 (n=33 668), eGFR30-60 (n=9803) and eGFR<30 (n=1735), respectively. After adjustment, ticagrelor as compared with clopidogrel was associated with a lower 1-year risk of the composite outcome (eGFR>60: HR 0.87, 95% CI 0.76 to 99, eGFR30-60: 0.82 (0.70 to 0.97), eGFR<30: 0.95 (0.69 to 1.29), P for interaction=0.55) and a higher risk of bleeding (eGFR>60: HR 1.10, 95% CI 0.90 to 1.35, eGFR30-60: 1.13 (0.84 to 1.51), eGFR<30: 1.79 (1.00 to 3.21), P for interaction=0.30) across the eGFR strata. CONCLUSIONS Treatment with ticagrelor as compared with clopidogrel in patients with MI was associated with lower risk for the composite of death, MI or stroke and a higher bleeding risk across all strata of eGFR. Of caution, bleeding events were more abundant in patients with eGFR<30.
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Affiliation(s)
- Robert Edfors
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Sahlén
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,National Heart Centre, Singapore, Singapore
| | - Karolina Szummer
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Renlund
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marie Evans
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Stefan K James
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christoph Varenhorst
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
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16
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Quantifying Ischemic Risk After Percutaneous Coronary Intervention Attributable to High Platelet Reactivity on Clopidogrel (From the Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents Study). Am J Cardiol 2017; 120:917-923. [PMID: 28754568 DOI: 10.1016/j.amjcard.2017.06.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/13/2017] [Accepted: 06/13/2017] [Indexed: 11/22/2022]
Abstract
Patients at high risk of thrombotic events after percutaneous coronary intervention (PCI) may potentially benefit from intensified antiplatelet therapy. However, more potent antiplatelet therapy would be expected to only overcome risk that is mediated by high platelet reactivity (PR). We used mediation analysis to determine the contribution of residual PR to the 2-year risk of major adverse cardiac events (MACE; the composite of cardiac death, myocardial infarction, or stent thrombosis) associated with clinical risk factors after PCI with drug-eluting stents (DES) in 8,374 patients from the prospective, multicenter Assessment of Dual AntiPlatelet Therapy with Drug-Eluting Stents (ADAPT-DES) registry. Residual PR on clopidogrel, as measured by the VerifyNow P2Y12 point-of-care assay, was included as a continuous linear mediator variable in Cox proportional hazards regression. Among 7 factors independently associated with 2-year MACE, residual PR partly mediated the effect of diabetes (13.4% attributable risk), anemia (22.9% attributable risk), and acute coronary syndromes (7.3% attributable risk). A PR-mediated effect inversely affected the MACE risk associated with smoking (10.4% attributable risk). The increased ischemic risk of chronic kidney disease, multivessel disease, and previous myocardial infarction were not mediated by residual PR. In conclusion, high residual PR mediates little or none of the increased 2-year MACE risk associated with baseline risk factors in patients treated with clopidogrel after successful PCI with DES. Intensifying antiplatelet therapy is therefore unlikely to substantially mitigate the excess ischemic risk from these variables.
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17
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Mavrakanas TA, Alam A, Reny JL, Fontana P. Platelet reactivity in stable cardiovascular patients with chronic kidney disease. Platelets 2017; 29:455-462. [PMID: 28580812 DOI: 10.1080/09537104.2017.1316485] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The study aimed to evaluate antiplatelet drug responsiveness in stable outpatients with cardiovascular disease and chronic kidney disease (CKD) and examine whether impaired antiplatelet drug responsiveness is associated with worse clinical outcomes in this population. Stable cardiovascular patients (n = 771) were enrolled at least one month after an acute ischemic atherothrombotic event. Antiplatelet drug responsiveness was assessed with specific assays (serum TxA2 for aspirin, the VASP assay for clopidogrel) and other aggregation-based assays using different agonists. All patients were followed until the first occurrence of a major adverse cardiovascular event. The 133 CKD patients were found to have higher activity of von Willebrand factor and higher fibrinogen levels. After a median follow-up of 33 months, 88 events occurred in patients without CKD and 31 events in patients with CKD (5.0 events and 8.7 events per 100 patient years, respectively, HR = 1.75 (95% CI 1.16-2.63; p = 0.008). The prevalence of poor aspirin and clopidogrel responsiveness and high platelet reactivity as assessed with different aggregation-based assays was similar in patients with estimated GFR ≥ 60 ml/min, 45-59 ml/min, and < 45 ml/min. No significant interaction for CKD vs. non-CKD was observed for events occurrence in patients with or without high platelet reactivity on several assays, with the exception of collagen-induced aggregation. In stable cardiovascular patients, CKD is not associated with higher platelet reactivity. Decreased antiplatelet drug responsiveness is not associated with worse clinical outcomes in CKD patients.
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Affiliation(s)
- Thomas A Mavrakanas
- a Nephrology Division , McGill University Health Center , Montreal , Canada.,b Division of General Internal Medicine , Geneva University Hospitals , Geneva , Switzerland
| | - Ahsan Alam
- a Nephrology Division , McGill University Health Center , Montreal , Canada
| | - Jean-Luc Reny
- c Division of Internal Medicine and Rehabilitation , Trois-Chêne, Geneva University Hospitals , Geneva , Switzerland.,d Geneva Platelet Group , Faculty of Medicine , Geneva , Switzerland
| | - Pierre Fontana
- d Geneva Platelet Group , Faculty of Medicine , Geneva , Switzerland.,e Division of Angiology and Hemostasis , Geneva University Hospitals , Geneva , Switzerland
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18
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Gargiulo G, Santucci A, Piccolo R, Franzone A, Ariotti S, Baldo A, Esposito G, Moschovitis A, Windecker S, Valgimigli M. Impact of chronic kidney disease on 2-year clinical outcomes in patients treated with 6-month or 24-month DAPT duration: An analysis from the PRODIGY trial. Catheter Cardiovasc Interv 2017; 90:E73-E84. [DOI: 10.1002/ccd.26921] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 12/19/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology; Bern University Hospital; Bern Switzerland
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Italy
| | - Andrea Santucci
- Department of Cardiology; Bern University Hospital; Bern Switzerland
| | - Raffaele Piccolo
- Department of Cardiology; Bern University Hospital; Bern Switzerland
| | - Anna Franzone
- Department of Cardiology; Bern University Hospital; Bern Switzerland
| | - Sara Ariotti
- Department of Cardiology; Bern University Hospital; Bern Switzerland
- Thoraxcenter, Erasmus Medical Center; Rotterdam The Netherlands
| | - Andrea Baldo
- Department of Cardiology; Bern University Hospital; Bern Switzerland
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences; Federico II University of Naples; Italy
| | - Aris Moschovitis
- Department of Cardiology; Bern University Hospital; Bern Switzerland
| | - Stephan Windecker
- Department of Cardiology; Bern University Hospital; Bern Switzerland
| | - Marco Valgimigli
- Department of Cardiology; Bern University Hospital; Bern Switzerland
- Thoraxcenter, Erasmus Medical Center; Rotterdam The Netherlands
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19
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Margolis G, Vig S, Flint N, Khoury S, Barkagan M, Keren G, Shacham Y. Prognostic Implications of Chronic Kidney Disease on Patients Presenting with ST-Segment Elevation Myocardial Infarction with versus without Stent Thrombosis. Cardiorenal Med 2017; 7:150-157. [PMID: 28611788 DOI: 10.1159/000455905] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/31/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Limited data is present regarding long-term outcomes in chronic kidney disease (CKD) patients presenting with stent thrombosis (ST). We evaluated the possible implications of CKD on long-term mortality in patients presenting with ST-segment elevation myocardial infarction (STEMI) and treated with primary percutaneous coronary intervention (PCI), and its interaction with the presence of ST. METHODS We retrospectively studied 1,722 STEMI patients treated with primary PCI. Baseline CKD was categorized as an estimated glomerular filtration rate <60 mL/min/1.73 m2 at presentation. The presence of ST was determined using the Academic Research Consortium definitions. Patients were evaluated for the presence of CKD and ST, as well as for long-term mortality. RESULTS A total of 448/1,722 (26%) patients had baseline CKD. Patients with CKD were older and had more comorbidities and a higher rate of ST (4 vs. 7%, respectively, p < 0.001). In a univariate analysis, long-term mortality was significantly higher among those with CKD compared to those without CKD (17.6 vs. 2.7%, p < 0.001). The presence of ST did not alter long-term mortality in both CKD and no-CKD patients. In a Cox regression model, CKD was an independent predictor of long-term mortality (hazard ratio 2.04, 95% confidence interval 1.17-3.56, p = 0.01), while ST as a covariate was not significantly associated with long-term mortality. CONCLUSION Among STEMI patients, CKD, but not ST, is a predictor of long-term mortality.
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Affiliation(s)
- Gilad Margolis
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Vig
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Flint
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shafik Khoury
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Barkagan
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gad Keren
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yacov Shacham
- Department of Cardiology, Tel Aviv Sourasky Medical Center Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Mathew RO, Bangalore S, Lavelle MP, Pellikka PA, Sidhu MS, Boden WE, Asif A. Diagnosis and management of atherosclerotic cardiovascular disease in chronic kidney disease: a review. Kidney Int 2016; 91:797-807. [PMID: 28040264 DOI: 10.1016/j.kint.2016.09.049] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 02/02/2023]
Abstract
Patients with chronic kidney disease (CKD) have a high prevalence of atherosclerotic cardiovascular disease, likely reflecting the presence of traditional risk factors. A greater distinguishing feature of atherosclerotic cardiovascular disease in CKD is the severity of the disease, which is reflective of an increase in inflammatory mediators and vascular calcification secondary to hyperparathyroidism of renal origin that are unique to patients with CKD. Additional components of atherosclerotic cardiovascular disease that are prominent in patients with CKD include microvascular disease and myocardial fibrosis. Therapeutic interventions that minimize cardiovascular events related to atherosclerotic cardiovascular disease in patients with CKD, as determined by well-designed clinical trials, are limited to statins. Data are lacking regarding other available therapeutic measures primarily due to exclusion of patients with CKD from major trials studying cardiovascular disease. Data from well-designed randomized controlled trials are needed to guide clinicians who care for this high-risk population in the management of atherosclerotic cardiovascular disease to improve clinical outcomes.
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Affiliation(s)
- Roy O Mathew
- Division of Nephrology, Department of Medicine, WJB Dorn VA Medical Center, Columbia, South Carolina, USA.
| | - Sripal Bangalore
- Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | | | | | - Mandeep S Sidhu
- Division of Cardiology, Department of Medicine, Stratton VA Medical Center, Albany, New York, USA; Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - William E Boden
- Division of Cardiology, Department of Medicine, Stratton VA Medical Center, Albany, New York, USA; Division of Cardiology, Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Neptune, New Jersey, USA
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21
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Barbieri L, Pergolini P, Verdoia M, Rolla R, Nardin M, Marino P, Bellomo G, Suryapranata H, De Luca G. Platelet reactivity in patients with impaired renal function receiving dual antiplatelet therapy with clopidogrel or ticagrelor. Vascul Pharmacol 2016; 79:11-15. [DOI: 10.1016/j.vph.2015.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/19/2015] [Accepted: 10/24/2015] [Indexed: 01/16/2023]
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22
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Guo LZ, Kim MH, Kim TH, Park JS, Jin E, Shim CH, Choi SY, Serebruany VL. Comparison of Three Tests to Distinguish Platelet Reactivity in Patients with Renal Impairment during Dual Antiplatelet Therapy. Nephron Clin Pract 2016; 132:191-7. [DOI: 10.1159/000444027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Accepted: 01/13/2016] [Indexed: 11/19/2022] Open
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23
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Polzin A, Dannenberg L, Sansone R, Levkau B, Kelm M, Hohlfeld T, Zeus T. Antiplatelet effects of aspirin in chronic kidney disease patients. J Thromb Haemost 2016; 14:375-80. [PMID: 26644261 DOI: 10.1111/jth.13211] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 11/24/2015] [Indexed: 12/21/2022]
Abstract
UNLABELLED ESSENTIALS: Chronic kidney disease (CKD) patients have a high risk of cardiovascular events. A pharmacodynamic evaluation of the effects of aspirin in 116 patients was carried out. The antiplatelet effects of aspirin are associated with impaired renal function. The optimal antithrombotic regimen in CKD patients must be investigated on a larger scale. BACKGROUND The pharmacodynamic response to aspirin varies significantly between individuals. Insufficient antiplatelet effects of aspirin are associated with increased risk of ischemic events. Chronic kidney disease (CKD) is suggested to affect the pharmacodynamic response to antiplatelet medication. High on-treatment platelet reactivity (HTPR) to clopidogrel has been reported to partially account for the enhanced risk of death and cardiovascular events in CKD patients. Objective To investigate the antiplatelet effects of aspirin in patients with CKD. METHODS We conducted a cross-sectional study in 116 patients on permanent aspirin medication. The pharmacodynamic response to aspirin was determined by arachidonic acid-induced thromboxane formation. RESULTS HTPR to aspirin was more frequent in patients with impaired renal function (47% vs. 22%; odds ratio, 3.16; 95% confidence interval [CI], 1.34-7.41; P = 0.008). The pharmacodynamic response to aspirin was impaired in patients with moderate/severe CKD (92; interquartile range [IQR], 282 ng mL(-1) ) as compared to patients with normal/mildly reduced renal function (36; IQR, 100 ng mL(-1) ; difference in medians, 57; CI, 5-110 ng mL(-1) ; P = 0.013). Bivariate Pearson analysis showed residual thromboxane formation to be correlated with glomerular filtration rate (R = -0.303; R(2) = 0.092; P = 0.001). Patients with CKD were older and more frequently female. Multivariate linear regression analysis revealed that the correlation was independent of age (R = -0.314; R(2) = 0.082; P = 0.002) and gender (R = -0.305; R(2) = 0.077; P = 0.006). CONCLUSION Renal function is correlated with pharmacodynamic response to aspirin. Patients with CKD have an increased risk of impaired antiplatelet effects of aspirin. Larger trials are needed to assess the clinical impact of this finding and investigate the optimal antithrombotic regimen in CKD patients.
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Affiliation(s)
- A Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - L Dannenberg
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - R Sansone
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - B Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - M Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - T Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Dusseldorf, Germany
| | - T Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
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Guo LZ, Kim MH, Shim CH, Choi SY, Serebruany VL. Impact of renal impairment on platelet reactivity and clinical outcomes during chronic dual antiplatelet therapy following coronary stenting. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:145-51. [DOI: 10.1093/ehjcvp/pvv052] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 12/07/2015] [Indexed: 01/09/2023]
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25
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Serebruany VL, Tomek A, Pokov AN, Kim MH. Clopidogrel, prasugrel, ticagrelor or vorapaxar in patients with renal impairment: do we have a winner? Expert Rev Cardiovasc Ther 2015; 13:1333-44. [PMID: 26513059 DOI: 10.1586/14779072.2015.1101343] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal utilization of antiplatelet therapy in patients with renal impairment (RI) following acute coronary syndromes (ACS) represents an urgent, unmet and yet unsolved need with regards to the choice of agents, duration of treatment and potential dose/regimen adjustment. The lack of any large randomized trials designed and powered specifically in such high-risk patients, absence of the uniformed efficacy and safety data reporting policy to the FDA and endless overoptimistic publications based on post hoc analyses of primary trials sometimes exaggerating benefits and hiding risks, clouds reality. In addition, triaging RI patients is problematic due to ongoing kidney deterioration and the fact that such patients are prone to both vascular occlusions and bleeding. The authors summarize available FDA-confirmed evidence from the latest trials with approved antiplatelet agents, namely clopidogrel (CAPRIE, CURE, CREDO, CLARITY, CHARISMA); prasugrel (TRITON, TRILOGY); ticagrelor (PLATO, and PEGASUS); and vorapaxar (TRACER and TRA2P) in RI patient cohorts on top of aspirin as part of dual antiplatelet therapy (DAPT). We deliberately avoided any results unless they were verified by the FDA, with the exception of the recent PEGASUS, since Agency reviews are not yet available. Despite differences among the trials and DAPT choices, RI patients universally experience much higher (HR = 1.3-3.1) rates of primary endpoint events, and bleeding risks (HR = 1.7-3.6). However, only ticagrelor increases creatinine and uric acid levels above that of clopidogrel; has the worst incidence of serious adverse events, more adverse events, and inferior outcomes in patients with severe (eGFR <30 ml/min), especially in the lowest (eGFR <15 ml/min) RI subsets. Clopidogrel, prasugrel and vorapaxar appear safer. Moreover, less aggressive half dose (5 mg/daily) prasugrel and strict DAPT, are well justified in RI, but not predominantly triple strategies with vorapaxar as tested in TRA2P and especially in TRACER. In conclusion, data from clinical trials, their sub-studies and affiliated FDA reviews indicate that RI cause more vascular occlusions and bleeding in ACS patients treated with DAPT. Among the novel antiplatelet agents, prasugrel and vorapaxar, but probably not ticagrelor, offer advantage in RI patients.
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Affiliation(s)
- Victor L Serebruany
- a Osler Medical Center , Towson , MD , USA.,b Department of Neurology , Johns Hopkins , Towson , MD , USA
| | - Ales Tomek
- c Department of Neurology , University of Prague , Prague , Czech Republic
| | | | - Moo Hyun Kim
- d Department of Cardiology , Dong-A University , Busan , Korea
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Melloni C, Cornel JH, Hafley G, Neely ML, Clemmensen P, Zamoryakhin D, Prabhakaran D, White HD, Fox KA, Ohman EM, Armstrong PW, Roe MT. Impact of chronic kidney disease on long-term ischemic and bleeding outcomes in medically managed patients with acute coronary syndromes: Insights from the TRILOGY ACS Trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:443-454. [PMID: 26228448 DOI: 10.1177/2048872615598631] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/12/2015] [Indexed: 11/16/2022]
Abstract
AIMS We aimed to study the relationship of chronic kidney disease stages with long-term ischemic and bleeding outcomes in medically managed acute coronary syndrome patients and the influence of more potent antiplatelet therapies on platelet reactivity by chronic kidney disease stage. METHODS AND RESULTS We estimated creatinine clearance for 8953 medically managed acute coronary syndrome patients enrolled in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes trial. Patients were classified by chronic kidney disease stage: normal renal function/mild (creatinine clearance >60 mL/min); moderate (creatinine clearance 30-60 mL/min); severe (creatinine clearance <30 mL/min). Kaplan-Meier event rates through 30 months were evaluated for ischemic (cardiovascular death, myocardial infarction or stroke; primary end point) and bleeding (Global Use of Strategies to Open Occluded Coronary Arteries and Thrombolysis In Myocardial Infarction bleeding) outcomes by chronic kidney disease stage and treatment allocation (prasugrel vs. clopidogrel) within each stage. Adjusted hazard ratios (95% confidence intervals) for moderate and for severe chronic kidney disease vs. normal/mild chronic kidney disease were estimated. Platelet reactivity at 30 days was assessed in a subset of patients (n = 1947). The majority of patients were in the normal/mild chronic kidney disease group (67%), followed by moderate chronic kidney disease (29%) and severe chronic kidney disease (4%). The incidence of ischemic and bleeding outcomes increased sharply across chronic kidney disease stages and no significant treatment interactions were observed. The adjusted risk of the primary end point increased across chronic kidney disease stages (moderate vs. normal/mild: hazard ratio 1.26; 95% confidence interval 1.09-1.46; severe vs. normal/mild: hazard ratio 1.60; 95% confidence interval 1.25-2.04). Platelet reactivity was lower in patients treated with prasugrel compared with clopidogrel, across all three chronic kidney disease stages. CONCLUSIONS Among medically managed acute coronary syndrome patients, the long-term risks of ischemic and bleeding outcomes increased markedly with worse chronic kidney disease stages. Despite lower platelet reactivity of prasugrel compared with clopidogrel, no treatment interactions for ischemic and bleeding outcomes were observed.
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Affiliation(s)
- Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, USA
| | - Jan H Cornel
- Department of Cardiology, Medical Center Alkmaar, the Netherlands
| | - Gail Hafley
- Duke Clinical Research Institute, Duke University School of Medicine, USA
| | - Megan L Neely
- Duke Clinical Research Institute, Duke University School of Medicine, USA
| | - Peter Clemmensen
- Nykoebing F Hospital, Faculty of Health Sciences, University of Copenhagen, Denmark
| | | | | | - Harvey D White
- Auckland City Hospital, Green Lane Cardiovascular Service, New Zealand
| | - Keith Aa Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | - E Magnus Ohman
- Duke Clinical Research Institute, Duke University School of Medicine, USA Division of Cardiology, Department of Medicine, Duke University School of Medicine, USA
| | - Paul W Armstrong
- Division of Cardiology and Canadian VIGOUR Centre, University of Alberta, Canada
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University School of Medicine, USA Division of Cardiology, Department of Medicine, Duke University School of Medicine, USA
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