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Parker WA, Orme RC, Hanson J, Stokes HM, Bridge CM, Shaw PA, Sumaya W, Thorneycroft K, Petrucci G, Porro B, Judge HM, Ajjan RA, Rocca B, Storey RF. Very-low-dose twice-daily aspirin maintains platelet inhibition and improves haemostasis during dual-antiplatelet therapy for acute coronary syndrome. Platelets 2019; 30:148-157. [PMID: 30759035 PMCID: PMC6425913 DOI: 10.1080/09537104.2019.1572880] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/04/2019] [Accepted: 01/11/2019] [Indexed: 01/11/2023]
Abstract
Higher aspirin doses may be inferior in ticagrelor-treated acute coronary syndrome (ACS) patients and reducing bleeding risk whilst maintaining antithrombotic benefits could improve outcomes. We characterized the pharmacodynamics of a novel dual-antiplatelet-therapy regimen consisting of very-low-dose twice-daily (BD) aspirin with standard-dose ticagrelor. A total of 20 ticagrelor-treated ACS patients entered a randomized crossover to take aspirin 20 mg BD (12-hourly) during one 14-day period and 75 mg once-daily (OD) in the other. After 14 days of treatment, serum thromboxane (TX)B2 and light-transmittance aggregometry were assessed pre- and 2 h post-morning-dose, bleeding time was measured post-dose, and TXA2 and prostacyclin stable metabolites were measured in urine collected 2 h post-morning-dose. Data are expressed as mean ± SD. After 14 days treatment, serum TXB2 levels were significantly greater 2 h post-dosing with aspirin 20 mg BD vs. 75 mg OD (3.0 ± 3.6 ng/mL vs. 0.8 ± 1.9 ng/mL; p = 0.018) whereas pre-dosing levels were not significantly different (3.5 ± 4.1 ng/mL vs. 2.5 ± 3.1 ng/mL, p = 0.23). 1-mmol/L arachidonic acid-induced platelet aggregation was similarly inhibited by both regimens pre-dose (8.5 ± 14.3% vs. 5.1 ± 3.6%, p = 0.24) and post-dose (8.7 ± 14.2% vs. 6.6 ± 5.3%; p = 0.41). Post-dose bleeding time was shorter with 20 mg BD (680 ± 306 s vs. 834 ± 386 s, p = 0.02). Urinary prostacyclin and TX metabolite excretion were not significantly different. In conclusion, compared to aspirin 75 mg OD, aspirin 20 mg BD provided consistent inhibition of platelet TXA2 release and aggregation, and improved post-dose hemostasis, in ticagrelor-treated ACS patients. Further studies are warranted to assess whether this regimen improves the balance of clinical efficacy and safety.
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Affiliation(s)
- William A.E. Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel C. Orme
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica Hanson
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Hannah M. Stokes
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Claire M. Bridge
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Patricia A. Shaw
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Wael Sumaya
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kirstie Thorneycroft
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Giovanna Petrucci
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Benedetta Porro
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico Cardiologico Monzino, Milan, Italy
| | - Heather M. Judge
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Ramzi A. Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, Cannon CP, Tanguay JF, Granger CB, Mauri L, Holmes DR, Gibson CM, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A North American Perspective-2016 Update. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.116.004395. [PMID: 27803042 DOI: 10.1161/circinterventions.116.004395] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation is an emerging clinical problem. Currently, there is limited evidenced-based data on the optimal antithrombotic treatment regimen, including antiplatelet and anticoagulant therapies, for these high-risk patients with practice guidelines, thus, providing limited recommendations. Over the past years, expert consensus documents have provided guidance to clinicians on how to manage patients with atrial fibrillation undergoing percutaneous coronary intervention. Given the recent advancements in the field, the current document provides an updated opinion of selected North American experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention. In particular, this document provides the current views on (1) embolic/stroke risk, (2) ischemic/thrombotic cardiac risk, and (3) bleeding risk, which are pivotal for discerning the choice of antithrombotic therapy. In addition, we describe the recent advances in pharmacology, stent designs, and clinical trials relevant to the field. Ultimately, we provide expert consensus-derived recommendations, using a pragmatic approach, on the management of patients with atrial fibrillation undergoing percutaneous coronary intervention.
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Affiliation(s)
- Dominick J Angiolillo
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
| | - Shaun G Goodman
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Deepak L Bhatt
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - John W Eikelboom
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Matthew J Price
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David J Moliterno
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Christopher P Cannon
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Jean-Francois Tanguay
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Christopher B Granger
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Laura Mauri
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David R Holmes
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - C Michael Gibson
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - David P Faxon
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
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