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Yang S, Kang J, Park KW, Hur SH, Lee NH, Hwang D, Yang HM, Ahn HS, Cha KS, Jo SH, Ryu JK, Suh IW, Choi HH, Woo SI, Han JK, Shin ES, Koo BK, Kim HS. Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic, and Bleeding Risks. J Am Coll Cardiol 2023; 82:1565-1578. [PMID: 37821166 DOI: 10.1016/j.jacc.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Clopidogrel was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI). OBJECTIVES The purpose of this study was to evaluate the benefits of clopidogrel across high-risk subgroups METHODS: This was a post hoc analysis of the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy) trial that randomly assigned patients who were event free for 6 to 18 months post-PCI on dual antiplatelet therapy (DAPT) to clopidogrel or aspirin monotherapy. Two clinical risk scores were used for risk stratification: the DAPT score and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) (the sum of age ≥75 years, diabetes, hypertension, current smoking, peripheral artery disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction). The primary composite endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission because of acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type ≥3) at 2 years after randomization. RESULTS Among 5,403 patients, clopidogrel monotherapy showed a lower rate of the primary composite endpoint than aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90). The benefit of clopidogrel over aspirin was consistent regardless of TRS 2°P (high TRS 2°P [≥3] group: HR: 0.65 [95% CI: 0.44-0.96]; and low TRS 2°P [<3] group: HR: 0.77 [95% CI: 0.60-0.99]) (P for interaction = 0.454) and regardless of DAPT score (high DAPT score [≥2] group: HR: 0.68 [95% CI: 0.46-1.00]; and low DAPT score [<2] group: HR: 0.75 [95% CI: 0.59-0.96]) (P for interaction = 0.662). The association was similar for the individual outcomes. CONCLUSIONS The beneficial effect of clopidogrel over aspirin monotherapy was consistent regardless of clinical risk or relative ischemic and bleeding risks compared with aspirin monotherapy. (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis- EXtended Antiplatelet Monotherapy [HOST-EXAM]; NCT02044250).
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Affiliation(s)
- Seokhun Yang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Seung-Ho Hur
- Keimyung University Dongsan Hospital, Daegu, Republic of Korea.
| | - Nam Ho Lee
- Kangnam Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Suk Ahn
- Uijeongbu St Mary's Hospital, Uijeongbu, Republic of Korea
| | - Kwang Soo Cha
- Pusan National University Hospital, Busan, Republic of Korea
| | - Sang-Ho Jo
- Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jae Kean Ryu
- Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Il-Woo Suh
- Anyang SAM Medical Center, Anyang, Republic of Korea
| | - Hyun-Hee Choi
- Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Seong-Ill Woo
- Inha University Hospital, Inha University, Incheon, Republic of Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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2
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Gewalt S, Lahu S, Ndrepepa G, Pellegrini C, Bernlochner I, Neumann FJ, Menichelli M, Morath T, Witzenbichler B, Wöhrle J, Hoppe K, Richardt G, Laugwitz KL, Schunkert H, Kastrati A, Schüpke S, Mayer K. Efficacy and Safety of Ticagrelor Versus Prasugrel in Women and Men with Acute Coronary Syndrome: A Pre-specified, Sex-Specific Analysis of the ISAR-REACT 5 Trial. J Atheroscler Thromb 2022; 29:747-761. [PMID: 33867409 PMCID: PMC9135658 DOI: 10.5551/jat.62776] [Citation(s) in RCA: 2] [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: 01/09/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022] Open
Abstract
AIM Sex-specific analyses of direct head-to-head comparisons between newer P2Y12 inhibitors are limited. This study was conducted to assess the efficacy and safety of ticagrelor versus prasugrel in women and men with acute coronary syndromes (ACS) planned for an invasive strategy. METHODS This pre-specified analysis of the ISAR-REACT 5 trial included 956 women and 3,062 men with ACS randomly assigned to either ticagrelor or prasugrel. The primary endpoint was the 12-month incidence of death, myocardial infarction, or stroke; the safety endpoint was the 12-month incidence of bleeding (type 3-5 according to the Bleeding Academic Research Consortium [BARC]). RESULTS The primary endpoint occurred in 42 women (8.9%) in the ticagrelor group and 39 women (8.3%) in the prasugrel group (hazard ratio [HR]=1.10, 95% confidence interval [CI] 0.71-1.70, P=0.657) and in 142 men (9.4%) in the ticagrelor group and 98 men (6.5%) in the prasugrel group (HR=1.47 [1.13-1.90], P=0.004; P for interaction [Pint]=0.275). BARC type 3-5 bleeding occurred in 36 women (9.7%) in the ticagrelor group and 34 women (9.7%) in the prasugrel group (HR=1.04 [0.65-1.67], P=0.856) and in 59 men in the ticagrelor group (4.4%) and 46 men (3.6%) in the prasugrel group (HR=1.24 [0.85-1.83], P=0.266; Pint=0.571). CONCLUSIONS Although there was no significant interaction between sex and treatment effect of study drugs, the superior efficacy of prasugrel was more evident among men. No difference in bleeding between the two study groups was seen for both women and men.
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Affiliation(s)
- Senta Gewalt
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Shqipdona Lahu
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Costanza Pellegrini
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg · Bad Krozingen
| | | | - Tanja Morath
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | | | - Jochen Wöhrle
- Department of Cardiology, Medical Campus Lake Constance
| | - Katharina Hoppe
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
| | | | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Katharina Mayer
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München
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3
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Tajchman DH, Nabi H, Aslam M, Butt JH, Grove EL, Engstrøm T, Holmvang L, Fosbøl EL, Køber L, Sørensen R. Initiation of and persistence with P2Y12 inhibitors in patients with myocardial infarction according to revascularization strategy: a nationwide study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:774-786. [PMID: 34570197 DOI: 10.1093/ehjacc/zuab043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/24/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND We aimed to analyse initiation of and persistence with P2Y12 inhibitors after first-time myocardial infarction (MI). METHODS AND RESULTS Using Danish nationwide registries, we identified patients ≥30 years with first-time MI during 1 January 2005-30 June 2016 and subsequent prescriptions of P2Y12 inhibitors. Independent factors related to initiation of and persistence with P2Y12 inhibitors were analysed by multivariable logistic regression and a Cox proportional hazards model. Patients were stratified by revascularization strategy: percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or medical therapy alone (MTA). Overall, 79 597 MI patients were included with 39 172 undergoing PCI, 2619 CABG, and 16 640 MTA, showing initiation of P2Y12 inhibitors of 93.4%, 49.0%, and 51.5%, respectively. Congestive heart failure, cerebrovascular disease, cardiac dysrhythmias, renal failure, previous bleeding, and oral anticoagulants were associated with less initiation of P2Y12 inhibitors. Female sex was associated with less initiation of P2Y12 inhibitors following MTA. MTA, coronary angiography, cerebrovascular disease, diabetes with complications, previous bleeding, antidiabetics, and ticagrelor as P2Y12 inhibitor were associated with non-persistence, whereas female sex, advanced age, and concomitant pharmacotherapy with angiotensin-converting enzyme inhibitors, beta-blockers, statins, oral anticoagulants, and aspirin were associated with high persistence. CONCLUSION Initiation of P2Y12 inhibitors in PCI-treated MI patients was high in contrast to those treated with CABG or MTA and patients with certain comorbidities. Further studies on the benefit-risk ratio of P2Y12 inhibitors in CABG-treated or MTA-treated patients and patients with comorbidities after first-time MI are warranted, as is focus on persistence among patients receiving MTA, patients with comorbidities, and users of ticagrelor.
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Affiliation(s)
- Daniel H Tajchman
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Hafsah Nabi
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Mohsin Aslam
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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4
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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5
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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6
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Jang JY, Jung HW, Lee BK, Shin DH, Kim JS, Hong SJ, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Park KW, Gwon HC, Kim HS, Kwon HM, Jang Y. Impact of PRECISE-DAPT and DAPT Scores on Dual Antiplatelet Therapy Duration After 2nd Generation Drug-Eluting Stent Implantation. Cardiovasc Drugs Ther 2020; 35:343-352. [PMID: 32588238 DOI: 10.1007/s10557-020-07008-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Determining the optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an important clinical issue. We evaluated the effects of ischemia (by DAPT score) and bleeding (by PRECISE-DAPT score), as well as the impact of DAPT duration, on clinical outcomes. METHODS From pooled analysis of four randomized clinical trials, 5131 patients undergoing second-generation DES implantation were randomized to short-duration (n = 2575; ≤ 6 months) or standard-duration (n = 2556; ≥ 12 months) DAPT groups. This population was further divided into four subgroups according to PRECISE-DAPT (high bleeding risk ≥ 25) and DAPT (high ischemic risk ≥ 2) scores. RESULTS Net clinical outcomes (1.3% vs. 1.3%; p = 0.89) and ischemic events (5.0% vs. 4.5%; p = 0.44) did not differ between the two duration groups, although bleeding events were more frequent in patients with standard-duration DAPT (0.4% vs. 0.9%; p = 0.04). Standard-duration DAPT was associated with fewer ischemic events (6.9% vs. 4.0%; p = 0.02) and no increase in bleeding events only among patients at low bleeding risk and high ischemic risk. The other groups show no differences in net clinical outcomes, ischemic events, or bleeding events according to DAPT duration. CONCLUSION Compared with short-duration DAPT, standard-duration DAPT was associated with similar net clinical outcomes and ischemic events, but more bleeding events at 12 months after second-generation DES implantation. However, standard-duration DAPT reduced ischemic events without increasing bleeding events among patients at low bleeding and high ischemic risk. When determining DAPT duration, considering both ischemic and bleeding risk can help optimize patient benefits. CLINICAL TRIAL REGISTRATION EXCELLENT (NCT00698607), RESET (NCT01145079), IVUS-XPL (NCT01308281), OPTIMA-C (NCT03056118).
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Affiliation(s)
- Ji-Yong Jang
- National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hae Won Jung
- Daegu Catholic University Medical Center, Daegu, South Korea
| | - Byoung-Kwon Lee
- Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, South Korea.
| | - Dong-Ho Shin
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Chul-Min Ahn
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Young-Guk Ko
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Donghoon Choi
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyung Woo Park
- Seoul National University Hospital School of Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, South Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital School of Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyuck Moon Kwon
- Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, South Korea
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.,Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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7
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Mar GY, Ridderstråle W, Wei J, Liu CP. Safety and Cumulative Incidence of Major Cardiovascular Events with Ticagrelor in Taiwanese Patients with Non-ST-Segment Elevation Myocardial Infarction: A 12-Month, Prospective, Phase IV, Multicenter, Single-Arm Study. ACTA CARDIOLOGICA SINICA 2020; 36:195-206. [PMID: 32425434 DOI: 10.6515/acs.202005_36(3).20191007b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Ticagrelor, an oral, direct-acting, and reversible P2Y12 receptor antagonist, inhibits platelet activation and aggregation. This phase IV, single-arm study analyzed the safety and tolerability of ticagrelor in Taiwanese patients with non-ST-segment elevation myocardial infarction (NSTEMI) during 1 year of follow-up. Methods Patients aged ≥ 20 years with an index event of NSTEMI received ticagrelor (180 mg loading and 90 mg doses twice daily thereafter) plus low-dose aspirin (100 mg/day) for up to 1 year. Safety was evaluated according to adverse events (AEs), serious AEs (SAEs), and PLATO-defined bleeding events. The cumulative incidence of major cardiovascular (CV) events including CV death, myocardial infarction, and stroke was also evaluated. Results The safety population included 108 patients across 13 centers in Taiwan. During treatment, 32 (29.6%) patients had ≥ one PLATO-defined bleeding event. Major bleeding events occurred in seven (6.5%) patients with a Kaplan-Meier (KM) estimated event risk [95% confidence interval (CI)] of 7.1% (3.4%-14.4%), including life-threatening bleeding [four (3.7%) patients] and other major bleeding [three (2.8%) patients]. No PLATO-defined fatal bleeding was observed. SAEs were reported in 23 (21.3%) patients. Six (5.6%) patients experienced major CV events during the 1-year follow-up period, with a KM-estimated event risk (95% CI) of 5.6% (2.6%-12.0%). Conclusions Ticagrelor for up to 1 year was associated with a low rate of major bleeding events and a low incidence of major CV events in Taiwanese patients with NSTEMI. The overall safety of ticagrelor was in accordance with the known safety profile of ticagrelor.
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Affiliation(s)
- Guang-Yuan Mar
- Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,College of Health and Nursing, Meiho University, Pingtung, Taiwan
| | | | | | - Chun-Peng Liu
- Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,College of Health and Nursing, Meiho University, Pingtung, Taiwan
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8
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Regev E, Asher E, Fefer P, Beigel R, Mazin I, Matetzky S. Acute myocardial infarction occurring while on chronic clopidogrel therapy ('clopidogrel failure') is associated with high incidence of clopidogrel poor responsiveness and stent thrombosis. PLoS One 2018; 13:e0195504. [PMID: 29624604 PMCID: PMC5889184 DOI: 10.1371/journal.pone.0195504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 03/24/2018] [Indexed: 11/19/2022] Open
Abstract
Objectives The clinical significance of the laboratory-based phenomenon of clopidogrel hypo-responsiveness and platelet reactivity associated with acute myocardial infarction, despite chronic clopidogrel therapy, is largely unknown. We aimed to determine platelet reactivity and clinical and angiographic features in 29 consecutive patients sustaining an acute myocardial infarction despite chronic (≥1 month) clopidogrel therapy. Methods Platelet reactivity was determined on admission using conventional aggregometry. All patients underwent coronary angiography within 24 hours of admission. Patients were matched with clopidogrel-naïve acute myocardial infarction patients. Clopidogrel-naïve patients received a 600 mg clopidogrel loading dose and 75 mg/day thereafter. Results Of the 29 study patients, 19 (66%) presented with ST-elevation myocardial infarction, and in 25% the infarction was related to angiographically-proved definite stent thrombosis. Two-thirds of these patients were poor responders to clopidogrel (adenosine diphosphate-induced platelet aggregation >50%) and dual antiplatelet poor responsiveness was found in 57% in the chronic clopidogrel therapy group. Compared with clopidogrel-naïve patients, chronic clopidogrel therapy patients were more likely to demonstrate clopidogrel poor responsiveness (66% versus 38%, p = 0.02), to be diabetic (52% versus 33%, p = 0.1) and to have multi-vessel coronary disease (79% versus 55%, p = 0.03). Conclusions Patients sustaining acute coronary syndrome despite chronic clopidogrel therapy are more likely to exhibit inadequate platelet inhibition with clopidogrel.
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Affiliation(s)
- Ehud Regev
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Asher
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paul Fefer
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Beigel
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Mazin
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
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9
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Squizzato A, Bellesini M, Takeda A, Middeldorp S, Donadini MP. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular events. Cochrane Database Syst Rev 2017; 12:CD005158. [PMID: 29240976 PMCID: PMC6486024 DOI: 10.1002/14651858.cd005158.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Aspirin is the prophylactic antiplatelet drug of choice for people with cardiovascular disease. Adding a second antiplatelet drug to aspirin may produce additional benefit for people at high risk and people with established cardiovascular disease. This is an update to a previously published review from 2011. OBJECTIVES To review the benefit and harm of adding clopidogrel to aspirin therapy for preventing cardiovascular events in people who have coronary disease, ischaemic cerebrovascular disease, peripheral arterial disease, or were at high risk of atherothrombotic disease, but did not have a coronary stent. SEARCH METHODS We updated the searches of CENTRAL (2017, Issue 6), MEDLINE (Ovid, 1946 to 4 July 2017) and Embase (Ovid, 1947 to 3 July 2017) on 4 July 2017. We also searched ClinicalTrials.gov and the WHO ICTRP portal, and handsearched reference lists. We applied no language restrictions. SELECTION CRITERIA We included all randomised controlled trials comparing over 30 days use of aspirin plus clopidogrel with aspirin plus placebo or aspirin alone in people with coronary disease, ischaemic cerebrovascular disease, peripheral arterial disease, or at high risk of atherothrombotic disease. We excluded studies including only people with coronary drug-eluting stent (DES) or non-DES, or both. DATA COLLECTION AND ANALYSIS We collected data on mortality from cardiovascular causes, all-cause mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal ischaemic stroke, major and minor bleeding. The overall treatment effect was estimated by the pooled risk ratio (RR) with 95% confidence interval (CI), using a fixed-effect model (Mantel-Haenszel); we used a random-effects model in cases of moderate or severe heterogeneity (I2 ≥ 30%). We assessed the quality of the evidence using the GRADE approach. We used GRADE profiler (GRADE Pro) to import data from Review Manager to create a 'Summary of findings' table. MAIN RESULTS The search identified 13 studies in addition to the two studies in the previous version of our systematic review. Overall, we included data from 15 trials with 33,970 people. We completed a 'Risk of bias' assessment for all studies. The risk of bias was low in four trials because they were at low risk of bias for all key domains (random sequence generation, allocation concealment, blinding, selective outcome reporting and incomplete outcome data), even if some of them were funded by the pharmaceutical industry.Analysis showed no difference in the effectiveness of aspirin plus clopidogrel in preventing cardiovascular mortality (RR 0.98, 95% CI 0.88 to 1.10; participants = 31,903; studies = 7; moderate quality evidence), and no evidence of a difference in all-cause mortality (RR 1.05, 95% CI 0.87 to 1.25; participants = 32,908; studies = 9; low quality evidence).There was a lower risk of fatal and non-fatal myocardial infarction with clopidogrel plus aspirin compared with aspirin plus placebo or aspirin alone (RR 0.78, 95% CI 0.69 to 0.90; participants = 16,175; studies = 6; moderate quality evidence). There was a reduction in the risk of fatal and non-fatal ischaemic stroke (RR 0.73, 95% CI 0.59 to 0.91; participants = 4006; studies = 5; moderate quality evidence).However, there was a higher risk of major bleeding with clopidogrel plus aspirin compared with aspirin plus placebo or aspirin alone (RR 1.44, 95% CI 1.25 to 1.64; participants = 33,300; studies = 10; moderate quality evidence) and of minor bleeding (RR 2.03, 95% CI 1.75 to 2.36; participants = 14,731; studies = 8; moderate quality evidence).Overall, we would expect 13 myocardial infarctions and 23 ischaemic strokes be prevented for every 1000 patients treated with the combination in a median follow-up period of 12 months, but 9 major bleeds and 33 minor bleeds would be caused during a median follow-up period of 10.5 and 6 months, respectively. AUTHORS' CONCLUSIONS The available evidence demonstrates that the use of clopidogrel plus aspirin in people at high risk of cardiovascular disease and people with established cardiovascular disease without a coronary stent is associated with a reduction in the risk of myocardial infarction and ischaemic stroke, and an increased risk of major and minor bleeding compared with aspirin alone. According to GRADE criteria, the quality of evidence was moderate for all outcomes except all-cause mortality (low quality evidence) and adverse events (very low quality evidence).
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Affiliation(s)
- Alessandro Squizzato
- University of InsubriaResearch Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, School of Medicinec/o Medicina 1, ASST Settelaghi Ospedale di Circoloviale Borri, 57VareseItaly21100
| | - Marta Bellesini
- University of InsubriaResearch Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, School of MedicineVareseItaly
| | - Andrea Takeda
- University College LondonFarr Institute of Health Informatics ResearchLondonUK
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Marco Paolo Donadini
- University of InsubriaResearch Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, School of MedicineVareseItaly
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10
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Abstract
BACKGROUND Patients over 75 account for more than one third of those presenting with myocardial infarction and more than 50% of intrahospital mortality. There are no specific guidelines for the management of acute coronary syndromes (ACS) in the elderly. SETTING Although antithrombotic therapy seems to be effective and safe in such patients, it requires specific precautions and treatment adjustments because of the higher bleeding risk due to comorbidities such as renal function impairment and malnutrition. RESULTS Scientific evidence concerning elderly patients is scarce as they are either excluded or underrepresented in most randomized trials. Overall, the antithrombotic therapy needs to be adapted to avoid complications, mainly bleeding complications, without compromising the effectiveness of the treatment in this high-risk population. CONCLUSION In the present paper, we review the current treatment strategies in ACS while focusing on data concerning the elderly, according to available data in pivotal trials and in both AHA/ACC and ESC guidelines.
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11
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Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
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12
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Sinnaeve PR, Desmet W, Descamps O, Gevaert S, De Backer G, Kolh P, Vrolix M, Van De Borne P, De Meester A, Claeys MJ, Beauloye C. One-year and longer dual antiplatelet therapy after an acute coronary syndrome: a Belgian position paper. Acta Cardiol 2017; 72:19-27. [PMID: 28597739 DOI: 10.1080/00015385.2017.1281563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Acute coronary syndrome patients receive DAPT up to one year after their initial event. Exceptions to the guideline-recommended one-year rule, however, are not uncommon. The reasoning behind shorter treatments, such as unacceptable bleeding risk or urgent surgery, should be well documented in the patient's charts and discharge letter. Based on recent evidence, patients at high risk for repetitive events should continue on low-dose ticagrelor without a significant interruption at one year and indefinitely in the absence of excess bleeding risk. As there is currently no reimbursement, policy makers and insurers should be made aware of the continuing risk and unmet clinical need in this patient population. Nevertheless, many unsolved questions need to be answered, both through additional analyses from recent trials such as PEGASUS-TIMI 54 or DAPT, as well as new carefully designed clinical studies.
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Affiliation(s)
- Peter R. Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Walter Desmet
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Descamps
- Department of Internal Medicine and Department of Cardiology, Centre Hospitalier Jolimont, Haine St. Paul, Belgium
- Department of Cardiovascular Diseases, Université Catholique de Louvain, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Ghent University Hospital, Gent, Belgium
| | - Guy De Backer
- Department of Public Health, Ghent University, Gent, Belgium
| | - Philippe Kolh
- Department of Cardiovascular Surgery, University Hospital (CHU, ULg) of Liège, Liège, Belgium
| | - Mathias Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Philippe Van De Borne
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Antoine De Meester
- Department of Internal Medicine and Department of Cardiology, Centre Hospitalier Jolimont, Haine St. Paul, Belgium
| | - Marc J. Claeys
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Christophe Beauloye
- Department of Cardiovascular Diseases, Université Catholique de Louvain, Cliniques Universitaires St-Luc, Brussels, Belgium
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13
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Ibrahim W, Mohamed A, Sheikh M, Shokr M, Hassan A, Wienberger J, Afonso LC. Antiplatelet Therapy and Spontaneous Retroperitoneal Hematoma: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:85-89. [PMID: 28119516 PMCID: PMC5286921 DOI: 10.12659/ajcr.901622] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patient: Male, 66 Final Diagnosis: Spontaneous retroperitoneal hematoma seconday dual antiplatelet therapy Symptoms: Anemia • knee joint pain Medication: — Clinical Procedure: None Specialty: Cardiology
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Affiliation(s)
- Walid Ibrahim
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA.,Detroit Medical Center, Detroit, MI, USA
| | | | - Muhammed Sheikh
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA.,Detroit Medical Center, Detroit, MI, USA
| | - Mohamed Shokr
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA.,Detroit Medical Center, Detroit, MI, USA
| | - Abubaker Hassan
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA.,Detroit Medical Center, Detroit, MI, USA
| | - Jarrett Wienberger
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA.,Detroit Medical Center, Detroit, MI, USA
| | - Luis C Afonso
- Detroit Medical Center, Detroit, MI, USA.,Division of Cardiology, Wayne State University, Detroit, MI, USA
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14
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Crawshaw J, Auyeung V, Norton S, Weinman J. Identifying psychosocial predictors of medication non-adherence following acute coronary syndrome: A systematic review and meta-analysis. J Psychosom Res 2016; 90:10-32. [PMID: 27772555 DOI: 10.1016/j.jpsychores.2016.09.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 09/01/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Medication non-adherence following acute coronary syndrome (ACS) is associated with poor clinical outcomes. A systematic review and meta-analysis were undertaken to identify psychosocial factors associated with medication adherence in patients with ACS. METHODS A search of electronic databases (Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, International Pharmaceutical Abstracts, CINAHL, ASSIA, OpenGrey, EthOS and WorldCat) was undertaken to identify relevant articles published in English between 2000 and 2014. Articles were screened against our inclusion criteria and data on study design, sample characteristics, predictors, outcomes, analyses, key findings and study limitations were abstracted. RESULTS Our search identified 3609 records, of which 17 articles met our inclusion criteria (15 independent studies). Eight out of ten studies found an association between depression and non-adherence. A meta-analysis revealed that depressed patients were twice as likely to be non-adherent compared to patients without depression (OR=2.00, 95% CI 1.57-3.33, p=0.015). Type D personality was found to predict non-adherence in both studies in which it was measured. Three out of three studies reported that treatment beliefs based on the Necessity-Concerns Framework predicted medication non-adherence and there was some evidence that social support was associated with better adherence. There was insufficient data to meta-analyse all other psychosocial factors identified. CONCLUSION There was some evidence that psychosocial factors, particularly depression, were associated with medication adherence following ACS. Targeting depressive symptoms, screening for Type D personality, challenging maladaptive treatment beliefs, and providing better social support for patients may be useful strategies to improve medication adherence.
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Affiliation(s)
- Jacob Crawshaw
- Institute of Pharmaceutical Science, King's College London, London, UK.
| | - Vivian Auyeung
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Sam Norton
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - John Weinman
- Institute of Pharmaceutical Science, King's College London, London, UK
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15
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Westerman ME, Sharma V, Scales J, Gearman DJ, Ingimarsson JP, Krambeck AE. The Effect of Antiplatelet Agents on Bleeding-Related Complications After Ureteroscopy. J Endourol 2016; 30:1073-1078. [DOI: 10.1089/end.2016.0447] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | - Joseph Scales
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Amy E. Krambeck
- Department of Urology, Mayo Clinic, Rochester, Minnesota
- IU Health Physicians, Indianapolis, Indiana
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16
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Xuereb R, Magri CJ, Xuereb S, Xuereb M, Mangion MZ, Xuereb RG. Female gender and cardiovascular disease. Br J Hosp Med (Lond) 2016; 77:454-9. [DOI: 10.12968/hmed.2016.77.8.454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Rachel Xuereb
- Third year medical student at the University of Malta, Malta
| | - Caroline J Magri
- Resident Specialist in the Department of Cardiology, Mater Dei Hospital, Tal-Qroqq, Msida MSD 2090, Malta, and Visiting Lecturer, University of Malta, Malta
| | - Sara Xuereb
- Foundation Year 2 Doctor in the Department of Medicine, Mater Dei Hospital, Malta
| | - Mariosa Xuereb
- Consultant Cardiologist in the Department of Cardiology, Mater Dei Hospital, and Visiting Senior Lecturer, University of Malta, Malta
| | | | - Robert G Xuereb
- Chairman and Consultant Cardiologist in the Department of Cardiology, Mater Dei Hospital, and Visiting Senior Lecturer, University of Malta, Malta
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17
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Timmis A, Rapsomaniki E, Chung SC, Pujades-Rodriguez M, Moayyeri A, Stogiannis D, Shah AD, Pasea L, Denaxas S, Emmas C, Hemingway H. Prolonged dual antiplatelet therapy in stable coronary disease: comparative observational study of benefits and harms in unselected versus trial populations. BMJ 2016; 353:i3163. [PMID: 27334486 PMCID: PMC4916922 DOI: 10.1136/bmj.i3163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To estimate the potential magnitude in unselected patients of the benefits and harms of prolonged dual antiplatelet therapy after acute myocardial infarction seen in selected patients with high risk characteristics in trials. DESIGN Observational population based cohort study. SETTING PEGASUS-TIMI-54 trial population and CALIBER (ClinicAl research using LInked Bespoke studies and Electronic health Records). PARTICIPANTS 7238 patients who survived a year or more after acute myocardial infarction. INTERVENTIONS Prolonged dual antiplatelet therapy after acute myocardial infarction. MAIN OUTCOME MEASURES Recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease. Fatal, severe, or intracranial bleeding. RESULTS 1676/7238 (23.1%) patients met trial inclusion and exclusion criteria ("target" population). Compared with the placebo arm in the trial population, in the target population the median age was 12 years higher, there were more women (48.6% v 24.3%), and there was a substantially higher cumulative three year risk of both the primary (benefit) trial endpoint of recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease (18.8% (95% confidence interval 16.3% to 21.8%) v 9.04%) and the primary (harm) endpoint of fatal, severe, or intracranial bleeding (3.0% (2.0% to 4.4%) v 1.26% (TIMI major bleeding)). Application of intention to treat relative risks from the trial (ticagrelor 60 mg daily arm) to CALIBER's target population showed an estimated 101 (95% confidence interval 87 to 117) ischaemic events prevented per 10 000 treated per year and an estimated 75 (50 to 110) excess fatal, severe, or intracranial bleeds caused per 10 000 patients treated per year. Generalisation from CALIBER's target subgroup to all 7238 real world patients who were stable at least one year after acute myocardial infarction showed similar three year risks of ischaemic events (17.2%, 16.0% to 18.5%), with an estimated 92 (86 to 99) events prevented per 10 000 patients treated per year, and similar three year risks of bleeding events (2.3%, 1.8% to 2.9%), with an estimated 58 (45 to 73) events caused per 10 000 patients treated per year. CONCLUSIONS This novel use of primary-secondary care linked electronic health records allows characterisation of "healthy trial participant" effects and confirms the potential absolute benefits and harms of dual antiplatelet therapy in representative patients a year or more after acute myocardial infarction.
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Affiliation(s)
- A Timmis
- The Farr Institute of Health Informatics Research, University College London, London, UK Barts and The London National Institute for Health Research, Cardiovascular Biomedical Research Unit, Bart's Heart Centre, London, UK
| | - E Rapsomaniki
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - S C Chung
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - M Pujades-Rodriguez
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - A Moayyeri
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - D Stogiannis
- Department of Mathematics, University of Athens, Athens, Greece
| | - A D Shah
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - L Pasea
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - S Denaxas
- The Farr Institute of Health Informatics Research, University College London, London, UK
| | - C Emmas
- AstraZeneca, Luton, Bedfordshire, UK
| | - H Hemingway
- The Farr Institute of Health Informatics Research, University College London, London, UK
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18
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Morphine in the setting of acute myocardial infarction: pros and cons. Am J Emerg Med 2016; 34:746-8. [PMID: 26874396 DOI: 10.1016/j.ajem.2016.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 01/13/2016] [Indexed: 11/20/2022] Open
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19
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Bang VV, Levy MS. Duration of dual anti-platelet therapy following drug eluting stents: Less Is More? Catheter Cardiovasc Interv 2016; 87:733-4. [PMID: 26994982 DOI: 10.1002/ccd.26491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/07/2016] [Indexed: 11/12/2022]
Abstract
This meta-analysis suggests that abbreviated DAPT (<6 months) could be considered in patients undergoing PCI with current generation drug eluting stents (DES). Extended DAPT strategy (>1 year) may be appropriate in those patients in whom prevention of stent and non-stent-related coronary events are likely to offset the bleeding complications. Additional randomized trials are needed to evaluate the optimum duration of DAPT in patients with the latest generation DES and current antiplatelet drugs.
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Affiliation(s)
- Vigyan V Bang
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Michael S Levy
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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20
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Hess CN, Hellkamp AS, Roe MT, Thomas L, Scirica BM, Peng SA, Peterson ED, Wang TY. Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization. J Am Heart Assoc 2016; 5:e002784. [PMID: 26976877 PMCID: PMC4943255 DOI: 10.1161/jaha.115.002784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non–ST‐segment elevation myocardial infarction patients who did not undergo coronary revascularization. Methods and Results We included unrevascularized non–ST‐segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry‐GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease (CAD; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD. Two‐year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all‐cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability‐weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD, and 34.7% (n=4915) had angiography with CAD. Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI]: 0.99 [0.93–1.06]), angiography without CAD (1.04 [0.74–1.47]), and angiography with CAD (1.12 [1.00–1.25], Pinteraction=0.20). Conclusions We found no association between discharge clopidogrel use and long‐term risk of major adverse cardiac events among older, unrevascularized non–ST‐segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.
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Affiliation(s)
- Connie N Hess
- University of Colorado School of Medicine, Aurora, CO
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21
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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22
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Verdoia M, Pergolini P, Rolla R, Nardin M, Barbieri L, Daffara V, Marino P, Bellomo G, Suryapranata H, Luca GD. Gender Differences in Platelet Reactivity in Patients Receiving Dual Antiplatelet Therapy. Cardiovasc Drugs Ther 2016; 30:143-50. [DOI: 10.1007/s10557-016-6646-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hobl EL, Reiter B, Schoergenhofer C, Schwameis M, Derhaschnig U, Kubica J, Stimpfl T, Jilma B. Morphine decreases ticagrelor concentrations but not its antiplatelet effects: a randomized trial in healthy volunteers. Eur J Clin Invest 2016; 46:7-14. [PMID: 26449338 DOI: 10.1111/eci.12550] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/04/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our recent drug interaction trial with clopidogrel shows that morphine decreases the concentrations and pharmacodynamic effects of clopidogrel, which could lead to treatment failure in susceptible individuals. We hypothesized that the pharmacodynamic consequences of drug-drug interactions would be less between morphine and ticagrelor. MATERIALS AND METHODS Twenty-four healthy subjects received a loading dose of 180 mg ticagrelor together with placebo or 5 mg morphine intravenously in a randomized, double-blind, placebo-controlled, crossover trial. Pharmacokinetics were determined by liquid chromatography tandem mass spectrometry, and ticagrelor pharmacodynamic effects were measured by platelet function tests (whole blood platelet aggregation: multiplate, platelet plug formation: PFA-100, vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay). RESULTS Concomitant i.v. injection of morphine slows drug resorption of ticagrelor and its active metabolite (P < 0·05) by 1 h and decreases plasma levels of ticagrelor and its active metabolite by 25-31% (P ≤ 0·03) and the drug exposure (area under the curve) by 22-23% (P ≤ 0·01). Importantly, however, the pharmacodynamic effects of ticagrelor on platelet aggregation in whole blood, platelet plug formation and VASP phosphorylation are not affected by morphine. CONCLUSIONS Morphine co-administration moderately decreases ticagrelor plasma concentrations but does not inhibit its pharmacodynamic effects in healthy volunteers within 6 h after drug administration. Limitations of our trial include the investigation in healthy volunteers under standardized conditions, which does not necessarily reflect a realistic emergency scenario.
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Affiliation(s)
- Eva-Luise Hobl
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Birgit Reiter
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Michael Schwameis
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ulla Derhaschnig
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Thomas Stimpfl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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McCune C, McKavanagh P, Menown IB. A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients. Cardiol Ther 2015; 4:95-116. [PMID: 26396083 PMCID: PMC4675753 DOI: 10.1007/s40119-015-0047-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Indexed: 12/21/2022] Open
Abstract
The elderly constitute a sizeable proportion of the acute coronary syndrome (ACS) population, and this population is continually increasing in number. Guideline-directed therapy is frequently underutilized in the elderly due to concerns about patient safety. However, studies suggest that this subgroup could benefit from many of the conventional and newer therapies available. This paper reviews current literature in the context of contemporary American and European guidance.
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Affiliation(s)
- Claire McCune
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, BT63 5QQ, UK.
| | - Peter McKavanagh
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, BT63 5QQ, UK
| | - Ian B Menown
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, BT63 5QQ, UK
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25
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Zhang L, Desai NR, Li J, Hu S, Wang Q, Li X, Masoudi FA, Spertus JA, Nuti SV, Wang S, Krumholz HM, Jiang L. National Quality Assessment of Early Clopidogrel Therapy in Chinese Patients With Acute Myocardial Infarction (AMI) in 2006 and 2011: Insights From the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE)-Retrospective AMI Study. J Am Heart Assoc 2015; 4:JAHA.115.001906. [PMID: 26163041 PMCID: PMC4608074 DOI: 10.1161/jaha.115.001906] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Early clopidogrel administration to patients with acute myocardial infarction (AMI) has been demonstrated to improve outcomes in a large Chinese trial. However, patterns of use of clopidogrel for patients with AMI in China are unknown. Methods and Results From a nationally representative sample of AMI patients from 2006 and 2011, we identified 11 944 eligible patients for clopidogrel therapy and measured early clopidogrel use, defined as initiation within 24 hours of hospital admission. Among the patients eligible for clopidogrel, the weighted rate of early clopidogrel therapy increased from 45.7% in 2006 to 79.8% in 2011 (P<0.001). In 2006 and 2011, there was significant variation in early clopidogrel use by region, ranging from 1.5% to 58.0% in 2006 (P<0.001) and 48.7% to 87.7% in 2011 (P<0.001). While early use of clopidogrel was uniformly high in urban hospitals in 2011 (median 89.3%; interquartile range: 80.1% to 94.5%), there was marked heterogeneity among rural hospitals (median 50.0%; interquartile range: 11.5% to 84.4%). Patients without reperfusion therapy and those admitted to rural hospitals were less likely to be treated with clopidogrel. Conclusions Although the use of early clopidogrel therapy in patients with AMI has increased substantially in China, there is notable wide variation across hospitals, with much less adoption in rural hospitals. Quality improvement initiatives are needed to increase consistency of early clopidogrel use for patients with AMI. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01624883.
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Affiliation(s)
- Lihua Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (N.R.D., H.M.K.)
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Shuang Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Qing Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, MO (J.A.S.)
| | - Sudhakar V Nuti
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.)
| | - Sisi Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (N.R.D., S.V.N., S.W., H.M.K.) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (N.R.D., H.M.K.) Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.) Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (L.Z., J.L., S.H., Q.W., X.L., L.J.)
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26
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Sampson AJ, Paul T, Stouffer GA. Pharmacological Therapy in the Management of Acute Coronary Syndromes. Atherosclerosis 2015. [DOI: 10.1002/9781118828533.ch40] [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: 11/10/2022]
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27
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Aronow WS. Antiplatelet Drug Use in Patients with Non-ST-Segment Elevation Acute Coronary Syndromes. Postgrad Med 2015; 125:51-8. [PMID: 23391671 DOI: 10.3810/pgm.2013.01.2624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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28
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Willerson JT, Armstrong PW. Medical Treatment of Unstable Angina and Acute Non-ST-Elevation Myocardial Infarction. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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29
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McQuillan BM, Thompson PL. Management of acute coronary syndrome in special subgroups: female, older, diabetic and Indigenous patients. Med J Aust 2014; 201:S91-6. [DOI: 10.5694/mja14.01248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/14/2014] [Indexed: 01/08/2023]
Affiliation(s)
- Brendan M McQuillan
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
| | - Peter L Thompson
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
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30
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Martínez-Quintana E, Tugores A. Clopidogrel: A multifaceted affair. J Clin Pharmacol 2014; 55:1-9. [DOI: 10.1002/jcph.413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/14/2014] [Indexed: 12/17/2022]
Affiliation(s)
- Efrén Martínez-Quintana
- Cardiology Department; Complejo Hospitalario Universitario Insular Materno Infantil; Las Palmas de Gran Canaria Spain
| | - Antonio Tugores
- Research Unit; Complejo Hospitalario Universitario Insular Materno Infantil; Las Palmas de Gran Canaria Spain
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31
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Solomon MD, Go AS, Shilane D, Boothroyd DB, Leong TK, Kazi DS, Chang TI, Hlatky MA. Comparative Effectiveness of Clopidogrel in Medically Managed Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2014; 63:2249-57. [DOI: 10.1016/j.jacc.2014.02.586] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 01/24/2014] [Accepted: 02/05/2014] [Indexed: 11/25/2022]
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Gasparovic H, Petricevic M, Kopjar T, Djuric Z, Svetina L, Biocina B. Impact of dual antiplatelet therapy on outcomes among aspirin-resistant patients following coronary artery bypass grafting. Am J Cardiol 2014; 113:1660-7. [PMID: 24666617 DOI: 10.1016/j.amjcard.2014.02.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 02/07/2014] [Accepted: 02/07/2014] [Indexed: 11/25/2022]
Abstract
Coronary artery bypass grafting is pivotal in the contemporary management of complex coronary artery disease. Interpatient variability to antiplatelet agents, however, harbors the potential to compromise the revascularization benefit by increasing the incidence of adverse events. This study was designed to define the impact of dual antiplatelet therapy (dAPT) on clinical outcomes among aspirin-resistant patients who underwent coronary artery surgery. We randomly assigned 219 aspirin-resistant patients according to multiple electrode aggregometry to receive clopidogrel (75 mg) plus aspirin (300 mg) or aspirin-monotherapy (300 mg). The primary end point was a composite outcome of all-cause death, nonfatal myocardial infarction, stroke, or cardiovascular hospitalization assessed at 6 months postoperatively. The primary end point occurred in 6% of patients assigned to dAPT and 10% of patients randomized to aspirin-monotherapy (relative risk 0.61, 95% confidence interval 0.25 to 1.51, p = 0.33). No significant treatment effect was noted in the occurrence of the safety end point. The total incidence of bleeding events was 25% and 19% in the dAPT and aspirin-monotherapy groups, respectively (relative risk 1.34, 95% confidence interval 0.80 to 2.23, p = 0.33). In the subgroup analysis, dAPT led to lower rates of adverse events in patients with a body mass index >30 kg/m(2) (0% vs 18%, p <0.01) and those <65 years (0% vs 10%, p = 0.02). In conclusion, the addition of clopidogrel in patients found to be aspirin resistant after coronary artery bypass grafting did not reduce the incidence of adverse events, nor did it increase the number of recorded bleeding events. dAPT did, however, lower the incidence of the primary end point in obese patients and those <65 years.
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33
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Chen SC, Hsiao FY, Lee CM, Hsu WWY, Gau CS. Duration of dual antiplatelet therapy following percutaneous coronary intervention on re-hospitalization for acute coronary syndrome. BMC Cardiovasc Disord 2014; 14:21. [PMID: 24533683 PMCID: PMC3974105 DOI: 10.1186/1471-2261-14-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 01/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background The optimal duration of dual antiplatelet therapy after percutaneous coronary intervention (PCI) remains uncertain. The objective of this study was to examine the association between duration of dual antiplatelet therapy and re-hospitalization for acute coronary syndrome (ACS) in ACS patients who underwent PCI. Methods We identified 975 newly diagnosed ACS patients who underwent PCI between July, 2007 and June, 2009, at a medical center in Taiwan. Cox proportional hazard models were used to examine the association between duration of dual antiplatelet therapy (9 months, 12 months and 15 months) and risks of re-hospitalization for ACS. Results At a mean follow-up of 2.3 years, we found that use of clopidogrel for ≥ 12 months was associated with a decreased risk of re-hospitalization for ACS (adjusted HR 0.59, 95% CI 0.36-0.95; p = 0.03). However, use of clopidogrel for ≥ 15 months was not associated with a decreased risk of re-hospitalization for ACS (adjusted HR 0.57, 95% CI 0.29-1.13; p = 0.11). Similar results were found in patients who implanted drug-eluting stents (DES), for whom at least 12 months of clopidogrel therapy is especially critical. Conclusion The benefit of ≥ 12 months of clopidogrel use in reducing the risk of re-hospitalization for ACS was significant among ACS patients who underwent PCI and was especially critical for those who implanted DES.
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Affiliation(s)
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, 33, Linsen South Road, Taipei, Taiwan.
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Gasparovic H, Petricevic M. P2Y12-based platelet function assays should be complemented with cyclooxygenase-dependent testing in framing the therapeutic windows for dual antiplatelet therapy. JACC Cardiovasc Interv 2014; 7:107-8. [PMID: 24456722 DOI: 10.1016/j.jcin.2013.09.005] [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: 08/29/2013] [Accepted: 09/03/2013] [Indexed: 10/25/2022]
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Abstract
In the United States, patent for branded Plavix has recently expired. Some studies have compared branded and generic clopidogrel in terms of pharmacokinetic parameters in healthy volunteers, but data on patients and clinical outcomes are scarce. We aimed to review efficacy and safety data from studies comparing Plavix with generic clopidogrel in patients with cardiovascular disease. Electronic databases were searched (from inception to May 2012) for prospective studies evaluating branded versus generic clopidogrel in patients with cardiovascular diseases. Studies' characteristics and data estimates were retrieved. Pooled risk ratio (RR) and 95% confidence intervals (95% CIs) were estimated through a random-effects model. Three studies evaluating 760 patients were included: 2 randomized controlled trials and 1 cohort study. The RR for major cardiovascular events was 1.01 (95% CI, 0.67-1.52). Incidence of adverse events was similar between Plavix and generic (RR 0.85; 95% CI, 0.49-1.48). The risks of mortality, bleeding, and drug discontinuation were also not different between groups. There are a limited number of studies comparing Plavix and generic clopidogrel in patients with cardiovascular diseases and reporting hard clinical end points. The available evidence is therefore limited and does not support the existence of differences in efficacy or safety between branded and generic clopidogrel.
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37
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Gasparovic H, Petricevic M, Biocina B. Impact and Diagnosis of Antiplatelet Therapy Resistance in Patients Undergoing Cardiac Surgery. Drug Dev Res 2013. [DOI: 10.1002/ddr.21107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Hrvoje Gasparovic
- Department of Cardiac Surgery; Clinical Hospital Center Zagreb; University of Zagreb; Zagreb; Croatia
| | - Mate Petricevic
- Department of Cardiac Surgery; Clinical Hospital Center Zagreb; University of Zagreb; Zagreb; Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery; Clinical Hospital Center Zagreb; University of Zagreb; Zagreb; Croatia
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Roe MT, Goodman SG, Ohman EM, Stevens SR, Hochman JS, Gottlieb S, Martinez F, Dalby AJ, Boden WE, White HD, Prabhakaran D, Winters KJ, Aylward PE, Bassand JP, McGuire DK, Ardissino D, Fox KAA, Armstrong PW. Elderly Patients With Acute Coronary Syndromes Managed Without Revascularization. Circulation 2013; 128:823-33. [DOI: 10.1161/circulationaha.113.002303] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background—
Dual antiplatelet therapy in older versus younger patients with acute coronary syndromes is understudied. Low-dose prasugrel (5 mg/d) is recommended for younger, lower-body-weight patients and elderly patients with acute coronary syndromes to mitigate the bleeding risk of standard-dose prasugrel (10 mg/d).
Methods and Results—
A total of 9326 medically managed patients with acute coronary syndromes from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial (<75 years of age, n=7243; ≥75 years of age, n=2083) were randomized to prasugrel (10 mg/d; 5 mg/d for those ≥75 or <75 years of age and <60 kg in weight) or clopidogrel (75 mg/d) plus aspirin for ≤30 months. A total of 515 participants ≥75 years of age (25% of total elderly population) had serial platelet reactivity unit measurements in a platelet-function substudy. Cumulative risks of the primary end point (cardiovascular death/myocardial infarction/stroke) and Thrombolysis in Myocardial Infarction (TIMI) major bleeding increased progressively with age and were ≥2-fold higher in older participants. Among those ≥75 years of age, TIMI major bleeding (4.1% versus 3.4%; hazard ratio, 1.09; 95% confidence interval, 0.57–2.08) and the primary end point rates were similar with reduced-dose prasugrel and clopidogrel. Despite a correlation between lower 30-day on-treatment platelet reactivity unit values and lower weight only in the prasugrel group, there was a nonsignificant treatment-by-weight interaction for platelet reactivity unit values among participants ≥75 years of age in the platelet-function substudy (
P
=0.06). No differences in weight were seen in all participants ≥75 years of age with versus without TIMI major/minor bleeding in both treatment groups.
Conclusions—
Older age is associated with substantially increased long-term cardiovascular risk and bleeding among patients with medically managed acute coronary syndromes, with no differences in ischemic or bleeding outcomes with reduced-dose prasugrel compared with clopidogrel in elderly patients. No significant interactions among weight, pharmacodynamic response, and bleeding risk were observed between reduced-dose prasugrel and clopidogrel in elderly patients.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov/ct2/home
. Unique identifier: NCT0069999.
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Affiliation(s)
- Matthew T. Roe
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Shaun G. Goodman
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - E. Magnus Ohman
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Susanna R. Stevens
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Judith S. Hochman
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Shmuel Gottlieb
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Felipe Martinez
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Anthony J. Dalby
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - William E. Boden
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Harvey D. White
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Dorairaj Prabhakaran
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Kenneth J. Winters
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Philip E. Aylward
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Jean-Pierre Bassand
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Darren K. McGuire
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Diego Ardissino
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Keith A. A. Fox
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
| | - Paul W. Armstrong
- From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., E.M.O., S.R.S.); Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC (M.T.R., E.M.O.); Division of Cardiology, Department of Medicine, St. Michael’s Hospital, Toronto, ON, Canada (S.G.G.); Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, New York University School of Medicine and NYU Langone Medical Center, New York (J.S.H.)
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Bawamia B, Mehran R, Qiu W, Kunadian V. Risk scores in acute coronary syndrome and percutaneous coronary intervention: a review. Am Heart J 2013; 165:441-50. [PMID: 23537960 DOI: 10.1016/j.ahj.2012.12.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
Patients with acute coronary syndrome (ACS) need to be risk stratified to deliver the most appropriate therapy. The GRACE and TIMI risk scores have penetrated contemporary guidelines with the former most commonly used in clinical practice. However, ACS prediction models need to be re-evaluated in contemporary practice with evolving diagnostic and treatment options. Moreover, the increased availability of percutaneous coronary intervention (PCI) as a treatment option for ACS combined with an expanding case mix and emphasis on quality control have triggered the creation of PCI specific prognostic models. These allow clinicians and patients to have an understanding of expected outcomes following PCI by predicting outcomes in-hospital to 5 years following intervention. The aim of this review is to evaluate the most recognized and studied ACS/PCI risk models, focusing on their strengths and limitations, and to assess the need for more robust tools to predict outcomes in a period of constantly advancing technologies and changing patient demographics.
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Abstract
Non-ST elevation (NSTE) myocardial infarction and unstable angina are the most common clinical presentations of acute coronary syndrome (ACS). Platelet activation is central to the pathogenesis of NSTE-ACS and consensus guidelines that advocate early revascularization supported by intensive antiplatelet therapy. This review examines the drugs used concurrently with aspirin as dual antiplatelet therapy in the NSTE-ACS setting. Clopidogrel represented an important therapeutic advance. However, variations in platelet response and a relatively slow onset of action compromise outcomes with clopidogrel. Evidence reviewed in this article shows that in NSTE-ACS patients, ticagrelor and prasugrel are more effective than clopidogrel and are relatively well tolerated, with an acceptable and manageable bleeding risk. The literature suggests several differences between ticagrelor and prasugrel that should allow clinicians to better tailor treatment to the patient. Head-to-head comparisons are now needed to compare directly the risks and benefits of ticagrelor and prasugrel in NSTE-ACS. Further studies also need to address other outstanding issues such as the benefits and risks of prasugrel pre-treatment and to stratify efficacy and tolerability according to diabetes mellitus (DM) and other co-morbidities. In the meantime, the issues discussed in this review should enhance clinicians' ability to optimize and individualize NSTE-ACS treatment, thereby further reducing the morbidity and mortality associated with this common cardiovascular condition.
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Affiliation(s)
- G Cayla
- Institut de Cardiologie, Bureau 236, Pitié-Salpêtrière University Hospital, 47-83, Bld de l'Hôpital, 75013 Paris, France
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41
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Results of a survey assessing provider beliefs of adherence barriers to antiplatelet medications. Crit Pathw Cardiol 2012; 10:134-41. [PMID: 21989034 DOI: 10.1097/hpc.0b013e318230d423] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The guidelines published by the American College of Cardiology Foundation/American Heart Association provide an evidence-based rationale and continuum of care for patients with unstable angina/non-ST-segment elevation acute coronary syndromes (UA/NSTE-ACS) from acute through to chronic management. Antiplatelet therapy forms an integral part of the care regimen, and a wealth of evidence supports appropriate dual or triple antiplatelet therapy in significantly reducing the frequency of potentially fatal secondary ischemic events. However, as is often the case with long-term therapies, adherence issues become apparent that limit this potential. In this article, we report on the results of a national survey of health care providers involved in the care of UA/NSTE-ACS patients on chronic (posthospital discharge) antiplatelet therapy. Our data reveal that the participants believe costs, lack of patient understanding of their condition or medication, and perception of the value of their therapy are important patient factors that promote nonadherence. Participants indicated that nonadherence occurs more frequently among minority and elderly patients, and less frequently when a caregiver is involved. We also show that deficits of knowledge, competence, and confidence exist in providers who treat patients with UA/NSTE-ACS. These deficits were generally greater in primary/family care providers compared with internal medicine and cardiologists, and for nurse practitioners/physician assistants compared with physicians (MDs/DOs). In addition, providers of all types frequently did not use adherence-improving tools or resources with their staff or patients. Our data suggest that because of its potential impact on patient outcomes, there is a pressing need to improve provider antiplatelet therapy adherence management in UA/NSTE-ACS.
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42
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Janknegt R, Ruiters L, ten Cate H. InforMatrix: ADP antagonists in acute coronary syndromes. Expert Opin Pharmacother 2012; 13:357-85. [DOI: 10.1517/14656566.2012.651460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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43
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Cea Soriano L, Bueno H, Johansson S, García Rodríguez LA. Predictors and time trends in clopidogrel and proton pump inhibitor coprescription with low-dose acetylsalicylic acid. Pharmacoepidemiol Drug Saf 2012; 21:463-9. [DOI: 10.1002/pds.3195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 11/14/2011] [Accepted: 11/28/2011] [Indexed: 12/23/2022]
Affiliation(s)
- Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
| | - Héctor Bueno
- Department of Cardiology; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | - Saga Johansson
- AstraZeneca R&D; Mölndal Sweden
- Institute of Medicine, Sahlgrenska Academy; Gothenburg University; Gothenburg Sweden
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44
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Stather DR, MacEachern P, Chee A, Tremblay A. Safety of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Patients Taking Clopidogrel: A Report of 12 Consecutive Cases. Respiration 2012; 83:330-4. [DOI: 10.1159/000335254] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 11/15/2011] [Indexed: 11/19/2022] Open
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45
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Alström U, Granath F, Friberg Ö, Ekbom A, Ståhle E. Risk factors for re-exploration due to bleeding after coronary artery bypass grafting. SCAND CARDIOVASC J 2011; 46:39-44. [DOI: 10.3109/14017431.2011.629004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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46
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Antithrombotic Pharmacotherapy in the Elderly: General Issues and Clinical Conundrums. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 14:57-68. [DOI: 10.1007/s11936-011-0153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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47
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Medvegy M, Simonyi G, Medvegy N, Pécsvárady Z. Non-ST elevation myocardial infarction: a new pathophysiological concept could solve the contradiction between accepted cause and clinical observations. ACTA PHYSIOLOGICA HUNGARICA 2011; 98:252-261. [PMID: 21893464 DOI: 10.1556/aphysiol.98.2011.3.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
UNLABELLED Non-ST elevation myocardial infarction (NSTEMI) and ST elevation infarction have many differences in their appearance and prognosis. A comprehensive search made us form a new hypothesis that a further cause also existsin NSTEMI: an acute, critical increase in the already existing high microvascular resistance in addition to the subtotal coronary artery occlusion. Various findings and studies can be interpreted only by our hypothesis: hemodynamic findings, ECG changes, autopsy reports and clinical observations (different long-time prognosis and different result of acute revascularization therapy in NSTEMI, similarities of NSTEMI with other clinical symptoms where increased microvascular resistance can be supposed without coronary artery disease). OBJECTIVE Despite similarities in the underlying pathologic mechanism non-ST elevation myocardial infarction(NSTEMI) and ST elevation infarction (STEMI) have many differences in their clinical presentation and prognosis. METHOD A systematic review of the literature about NSTEMI and the blood supply of the myocardium made us form a hypothesis that a further cause also exists in addition to the accepted cause of NSTEMI (subtotal coronaryartery occlusion): an acute, critical increase in an already existing high intramyocardial microvascular resistance. EVIDENCE Knowledge about microcirculation disturbances in ischemic heart disease and development of microcirculation damage can be fitted in our hypothesis. Various findings and studies can be interpreted only by our hypothesis: hemodynamic findings, ECG changes, autopsy reports and clinical observations about NSTEMI. The latest ones involve the different long-time prognosis and different result of acute revascularization therapy in STEMI and NSTEMI. Regarding the repolarization changes on the ECG NSTEMI shows similarities with other clinical symptoms where increased intramyocardial microvascular resistance can be supposed without coronary artery disease: false positive exercise stress test, supraventricular tachycardia, left ventricular strain and conduction disturbances. CONCLUSION The acute treatment of NSTEMI should aim to improve the blood inflow to the stiff myocardiumand/or impaired microvascular system and decrease the high microvascular resistance.
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48
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Alatorre CI, Carter GC, Chen C, Villarivera C, Zarotsky V, Cantrell RA, Goetz I, Paczkowski R, Buesching D. A comprehensive review of predictive and prognostic composite factors implicated in the heterogeneity of treatment response and outcome across disease areas. Int J Clin Pract 2011; 65:831-47. [PMID: 21718398 DOI: 10.1111/j.1742-1241.2011.02703.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIM To assess and present the current body of evidence regarding composite measures associated with differential treatment response or outcome as a result of patient heterogeneity and to evaluate their consistency across disease areas. METHODS A comprehensive review of the literature from the last 10 years was performed using three databases (PubMed, Embase and Cochrane). All articles that met the inclusion/exclusion criteria were selected, abstracted and assessed using the NICE level-of-evidence criteria. RESULTS Forty-nine studies were identified in the data abstraction. Approximately one-third focused on existing composite measures, and the rest investigated emerging composite factors. The majority of studies targeted patients with cancer, cardiovascular disease or psychological disorders. As a whole, the composite measures were found to be disease-specific, but some composite elements, including age, gender, comorbidities and health status, showed consistency across disease areas. To complement these findings, common individual factors found in five previous independent disease-specific literature assessments were also summarised, including age, gender, treatment adherence and satisfaction, healthcare resource utilisation and health status. CONCLUSIONS Composite measures can play an important role in characterising heterogeneity of treatment response and outcome in patients suffering from various medical conditions. These measures can help clinicians to better distinguish between patients with high likelihood to respond well to treatment and patients with minimal chances of positive therapeutic outcomes. Herein, the individual factors identified can be used to develop novel predictive or prognostic composite measures that can be applicable across disease areas. Reflecting these cross-disease measures in clinical and public health decisions has the distinctive appeal to enable targeted treatment for patients suffering from multiple medical conditions, which may ultimately yield significant gains in individual outcomes, population health and cost-effective resource allocation.
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Affiliation(s)
- C I Alatorre
- Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN 46285, USA.
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James SK, Roe MT, Cannon CP, Cornel JH, Horrow J, Husted S, Katus H, Morais J, Steg PG, Storey RF, Stevens S, Wallentin L, Harrington RA. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ 2011; 342:d3527. [PMID: 21685437 PMCID: PMC3117310 DOI: 10.1136/bmj.d3527] [Citation(s) in RCA: 191] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate efficacy and safety outcomes in patients in the PLATelet inhibition and patient Outcomes (PLATO) trial who at randomisation were planned for a non-invasive treatment strategy. DESIGN Pre-specified analysis of pre-randomisation defined subgroup of prospective randomised clinical trial. SETTING 862 centres in 43 countries. PARTICIPANTS 5216 (28%) of 18,624 patients admitted to hospital for acute coronary syndrome who were specified as planned for non-invasive management. INTERVENTIONS Randomised treatment with ticagrelor (n=2601) versus clopidogrel (2615). MAIN OUTCOME MEASUREMENTS Primary composite end point of cardiovascular death, myocardial infarction, and stroke; their individual components; and PLATO defined major bleeding during one year. RESULTS 2183 (41.9%) patients had coronary angiography during their initial hospital admission, 1065 (20.4%) had percutaneous coronary intervention, and 208 (4.0%) had coronary artery bypass surgery. Cumulatively, 3143 (60.3%) patients had been managed non-invasively by the end of follow-up. The incidence of the primary end point was lower with ticagrelor than with clopidogrel (12.0% (n=295) v 14.3% (346); hazard ratio 0.85, 95% confidence interval 0.73 to 1.00; P=0.04). Overall mortality was also lower (6.1% (147) v 8.2% (195); 0.75, 0.61 to 0.93; P=0.01). The incidence of total major bleeding (11.9% (272) v 10.3% (238); 1.17, 0.98 to 1.39; P=0.08) and non-coronary artery bypass grafting related major bleeding (4.0% (90) v 3.1% (71); 1.30, 0.95 to 1.77; P=0.10) was numerically higher with ticagrelor than with clopidogrel. CONCLUSIONS In patients with acute coronary syndrome initially intended for non-invasive management, the benefits of ticagrelor over clopidogrel were consistent with those from the overall PLATO results, indicating the broad benefits of P2Y12 inhibition with ticagrelor regardless of intended management strategy. TRIAL REGISTRATION Clinical trials NCT00391872.
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Affiliation(s)
- Stefan K James
- Uppsala Clinical Research Center, Uppsala University, Sweden.
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Early clopidogrel use in non-ST elevation acute coronary syndrome and subsequent coronary artery bypass grafting. Am Heart J 2011; 161:832-41. [PMID: 21570511 DOI: 10.1016/j.ahj.2011.01.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Accepted: 01/21/2011] [Indexed: 11/21/2022]
Abstract
Clopidogrel use is associated with a significant decrease in major adverse cardiac events when used in patients with non-ST elevation acute coronary syndromes (NSTE-ACS), and guidelines give a class I level of evidence A recommendation for the use of clopidogrel in these patients. The optimal timing of clopidogrel use has not been conclusively determined, but nearly all data available support early use in patients with NSTE-ACS. Despite this, clopidogrel usage is far less than expected based on current guidelines because of concern for bleeding at the time of possible subsequent coronary artery bypass grafting (CABG). Clopidogrel use has been associated with increased perioperative bleeding at the time of CABG, but data are mixed. Numerous studies have conclusively shown that this bleeding risk is confined to those patients receiving clopidogrel within 5 days of CABG. The absolute number of patients exposed to this possible bleeding risk is very small relative to the >1 million patients who present annually with NSTE-ACS and is estimated to be <0.8% of these patients. Recent data have shown that (1) holding clopidogrel for 5 days before CABG is safe in patients with NSTE-ACS and (2) clopidogrel use in patients with NSTE-ACS decreases ischemic events in patients referred for CABG compared to patients who are not given clopidogrel. These data strongly challenge the notion that clopidogrel should be withheld until it is determined if the patient will be referred for CABG.
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