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Birocchi S, Rocchetti M, Minardi A, Podda GM, Squizzato A, Cattaneo M. Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design. Thromb Haemost 2024; 124:482-496. [PMID: 37549688 DOI: 10.1055/a-2149-4344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND The value of guided therapy (GT) with anti-P2Y12 drugs in percutaneous coronary intervention (PCI) is unclear. Meta-analyses lumped together randomized controlled trials (RCTs) with heterogeneous designs, comparing either genotype-GT or platelet function test (PFT)-GT with unguided therapy. Some meta-analysis also included RCTs that did not explore GT, but included the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy). We performed three distinct systematic reviews/meta-analyses, each exploring only RCTs with homogeneous design. METHODS MEDLINE, Embase, and Central databases were searched for RCTs testing genotype-GT, PFT-GT, or HTPR-Therapy in PCI-treated patients, through October 1, 2022. Two reviewers extracted the data. Risk ratios (RRs) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MBs) and major adverse cardiovascular events (MACE). RESULTS In seven genotype-GT RCTs, RRs were: MB, 1.06 (0.73-1.54; p = 0.76); MACE, 0.65 (0.47-0.91; p = 0.01), but significant risk reduction was observed in RCTs performed in China (0.30, 0.16-0.54; p < 0.0001) and not elsewhere (0.75, 0.48-1.18; p = 0.21). In six PFT-GT RCTs, RRs were: MB, 0.91 (0.64-1.28, p = 0.58); MACE, 0.82 (0.56-1.19; p = 0.30): 0.62 (0.42-0.93; p = 0.02) in China, 1.08 (0.82-1.41; p = 0.53) elsewhere. In eight HTPR-Therapy RCTs, RRs were: MB, 0.71 (0.41-1.23; p = 0.22); MACE, 0.57 (0.44-0.75; p < 0.0001): 0.56 (0.43-0.74, p < 0.0001) in China, 0.58 (0.27-1.23, p = 0.16) elsewhere. CONCLUSION No GT strategy affected MB. Overall, genotype-GT but not PFT-GT reduced MACE. However, genotype-GT and PFT-GT reduced MACE in China, but not elsewhere. PFT-GT performed poorly compared to HTPR-Therapy, likely due to inaccurate identification of HTPR patients by PFT.
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Affiliation(s)
- Simone Birocchi
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Matteo Rocchetti
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Minardi
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Gian Marco Podda
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Marco Cattaneo
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
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Capodanno D, Angiolillo DJ. Personalised antiplatelet therapies for coronary artery disease: what the future holds. Eur Heart J 2023; 44:3059-3072. [PMID: 37345589 DOI: 10.1093/eurheartj/ehad362] [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: 03/05/2023] [Revised: 05/07/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023] Open
Abstract
Coronary artery disease (CAD) is one of the leading causes of death globally, and antiplatelet therapy is crucial for both its prevention and treatment. Antiplatelet drugs such as aspirin and P2Y12 inhibitors are commonly used to reduce the risk of thrombotic events, including myocardial infarction, stroke, and stent thrombosis. However, the benefits associated with the use of antiplatelet drugs also come with a risk of bleeding complications. The ever-growing understanding of the poor prognostic implications associated with bleeding has set the foundations for defining strategies that can mitigate such safety concern without any trade-off in antithrombotic protection. To this extent, personalised antiplatelet therapy has emerged as a paradigm that optimizes the balance between safety and efficacy by customizing treatment to the individual patient's needs and risk profile. Accurate risk stratification for both bleeding and thrombosis can aid in selecting the optimal antiplatelet therapy and prevent serious and life-threatening outcomes. Risk stratification has traditionally included clinical and demographic characteristics and has expanded to incorporate angiographic features and laboratory findings. The availability of bedside platelet function testing as well as rapid genotyping assays has also allowed for a more individualized selection of antiplatelet therapy. This review provides a comprehensive overview of the current state of the art and future trends in personalised antiplatelet therapy for patients with CAD, with emphasis on those presenting with an acute coronary syndrome and undergoing percutaneous coronary revascularization. The aim is to provide clinicians with a comprehensive understanding of personalised antiplatelet therapy and facilitate informed clinical decision-making.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria 'G. Rodolico - San Marco', University of Catania, Via Santa Sofia, 78 - 95123 Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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Levens AD, den Haan MC, Jukema JW, Heringa M, van den Hout WB, Moes DJAR, Swen JJ. Feasibility of Community Pharmacist-Initiated and Point-of-Care CYP2C19 Genotype-Guided De-Escalation of Oral P2Y12 Inhibitors. Genes (Basel) 2023; 14:genes14030578. [PMID: 36980851 PMCID: PMC10048116 DOI: 10.3390/genes14030578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
Tailoring antiplatelet therapy based on CYP2C19 pharmacogenetic (PGx) testing can improve cardiovascular outcomes and potentially reduce healthcare costs in patients on a P2Y12-inhibitor regime with prasugrel or ticagrelor. However, ubiquitous adoption—particularly in an outpatient setting—remains limited. We conducted a proof-of-concept study to evaluate the feasibility of CYP2C19-guided de-escalation of prasugrel/ticagrelor to clopidogrel through point-of-care (POC) PGx testing in the community pharmacy. Multiple feasibility outcomes were assessed. Overall, 144 patients underwent CYP2C19 PGx testing in 27 community pharmacies. Successful test results were obtained in 142 patients (98.6%). De-escalation to clopidogrel occurred in 19 patients (20%) out of 95 (67%) eligible for therapy de-escalation, which was mainly due to PGx testing not being included in cardiology guidelines. Out of the 119 patients (84%) and 14 pharmacists (100%) surveyed, 109 patients (92%) found the community pharmacy a suitable location for PGx testing, and the majority of pharmacists (86%) thought it has added value. Net costs due to PGx testing were estimated at €43 per patient, which could be reduced by earlier testing and could turn into savings if de-escalation would double to 40%. Although the observed de-escalation rate was low, POC CYP2C19-guided de-escalation to clopidogrel appears feasible in a community pharmacy setting.
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Affiliation(s)
- Amar D. Levens
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Melina C. den Haan
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, 2331 JE Leiden, The Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Correspondence:
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Application of Pharmacogenetics for the Use of Antiplatelet and Anticoagulant Drugs. CURRENT CARDIOVASCULAR RISK REPORTS 2023. [DOI: 10.1007/s12170-022-00713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Zhong PY, Deng JP, Zhao JH, Peng L, Liu T, Wang HY. Guided vs. conventional anti-platelet therapy for patients with acute coronary syndrome: A meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1079332. [PMID: 37025677 PMCID: PMC10070678 DOI: 10.3389/fcvm.2023.1079332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/24/2023] [Indexed: 04/08/2023] Open
Abstract
Background Whether guided antiplatelet therapy in patients with acute coronary syndrome (ACS) is effective in improving net clinical benefits compared with conventional antiplatelet therapy remains controversial. Therefore, we assessed the safety and efficacy of guided antiplatelet therapy in patients with ACS and undergoing percutaneous coronary intervention. Method We searched PubMed, EMBASE, and Cochrane Library databases to select the relevant randomized controlled trials comparing the guided and conventional antiplatelet therapy in patients with ACS. The primary and safety outcomes are major adverse cardiovascular events (MACE) and major bleeding, respectively. The efficacy outcomes included myocardial infarction, stent thrombosis, all-cause death, and cardiovascular death. We selected the relative risk (RR) and 95% confidence intervals (CIs) as effect size and calculated it using the Review Manager software. In addition, we evaluated the final results by trial sequential analysis (registered by PROSPERO, CRD 42020210912). Results We selected seven randomized controlled trials and included 8,451 patients in this meta-analysis. Guided antiplatelet therapy can significantly reduce the risk of MACE (RR 0.64, 95% CI 0.54-0.76, P < 0.00001), myocardial infarction (RR 0.62, 95% CI 0.49-0.79, P = 0.0001), all-cause death (RR 0.61, 95% CI 0.44-0.85, P = 0.003), and cardiovascular death (RR 0.66, 0.49-0.90, P = 0.009). In addition, there is no significant difference between the two groups in stent thrombosis (RR 0.67, 95% CI 0.44-1.03, P = 0.07) and major bleeding (RR 0.86, 95% CI 0.65-1.13, P = 0.27). The subgroup analysis showed that the guided group based on genotype tests could bring benefits in MACE and myocardial infarction. Conclusions The guided antiplatelet therapy is not only associated with a comparable risk of bleeding but also with a lower risk of MACE, myocardial infarction, all-cause death, cardiovascular death, and stent thrombosis than the conventional strategy in patients with ACS.
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Affiliation(s)
- Peng-Yu Zhong
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
| | - Jian-Ping Deng
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
| | - Jing-Hong Zhao
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
| | - Lei Peng
- Department of Urology, The Second Hospital of Lanzhou University Medical School, Lanzhou, China
- South China Hospital, Health Science Center, Shenzhen University, Shenzhen, China
| | - Tao Liu
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
- Correspondence: Tao Liu Hao-Yu Wang
| | - Hao-Yu Wang
- Department of Cardiology, Nanchong Central Hospital, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, China
- Correspondence: Tao Liu Hao-Yu Wang
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Marcucci R, Berteotti M, Gragnano F, Galli M, Cavallari I, Renda G, Capranzano P, Santilli F, Capodanno D, Angiolillo DJ, Cirillo P, Calabrò P, Patti G, De Caterina R. Monitoring antiplatelet therapy: where are we now? J Cardiovasc Med (Hagerstown) 2022; 24:e24-e35. [PMID: 36729588 DOI: 10.2459/jcm.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Single antiplatelet therapy represents the cornerstone of thrombosis prevention in atherosclerotic cardiovascular disease. Dual antiplatelet therapy (DAPT), consisting of aspirin plus a P2Y12 inhibitor, is the standard of care for patients with acute coronary syndrome or undergoing both coronary and peripheral percutaneous interventions. Recent data suggest the efficacy of DAPT also after minor stroke. In this setting, a large body of evidence has documented that genetic and acquired patients' characteristics may affect the magnitude of platelet inhibition induced by antiplatelet agents. The implementation of tools allowing the identification and prediction of platelet inhibition has recently been shown to improve outcomes, leading to an optimal balance between antithrombotic efficacy and bleeding risk. We are therefore clearly moving towards tailored antiplatelet therapy. The aim of this paper is to summarize the available evidence on the evaluation of platelet inhibition in patients with coronary, peripheral, or cerebrovascular atherosclerosis. We will here focus on antiplatelet therapy based on both aspirin and P2Y12 inhibitors. In addition, we provide practical insights into the clinical settings in which it appears reasonable to implement antiplatelet therapy monitoring.
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Affiliation(s)
- Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Martina Berteotti
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Felice Gragnano
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome.,Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | | | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara
| | - Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Francesca Santilli
- Department of Medicine and Aging, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples
| | - Paolo Calabrò
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Giuseppe Patti
- Maggiore della Carità Hospital, University of Eastern Piedmont, Novara
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa.,Division of Cardiology, Azienda Ospedaliero-Universitaria Pisana, Pisa.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Pescara, Italy
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Djordjevic N. Genotyping genetic variants of CYP2C19 for precision antiplatelet dosing: state of the art and future perspectives. Expert Opin Drug Metab Toxicol 2022; 18:817-830. [PMID: 36606363 DOI: 10.1080/17425255.2022.2166486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Clopidogrel is the only antiplatelet agent whose activity is significantly affected by CYP2C19 polymorphism. AREAS COVERED This review has summarized the available evidence on the clinically significant association between CYP2C19 polymorphism and clopidogrel-based therapy; reviewed the current recommendations for clinical use of CYP2C19 genotype test results in patients on clopidogrel treatment; and discussed possible pitfalls of routine application, and future perspectives of antiplatelets pharmacogenetics. EXPERT OPINION The available body of evidence, reflected in several meta-analyses and high-quality clinical practice guidelines, shows that the presence of CYP2C19 LOF alleles, especially CYP2C19*2, correlates with impaired activation of clopidogrel and variable platelet inhibition, followed by minimal or no antiplatelet effect, and higher risk of treatment failure. In combination with other known risk factors, CYP2C19 genetic testing could be very valuable in predicting low clopidogrel efficacy. At the same time, it could be very successful in selecting patients who will most probably benefit from the clopidogrel-based therapy, thus decreasing the pool of those who might need more expensive and otherwise riskier antiplatelet alternatives.
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Affiliation(s)
- Natasa Djordjevic
- Faculty of Medical Sciences, Department of Pharmacology and Toxicology, University of Kragujevac, Svetozara Markovica 69, 34 000 Kragujevac, Serbia
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Escalation and De-Escalation of Antiplatelet Therapy after Acute Coronary Syndrome or PCI: Available Evidence and Implications for Practice. J Clin Med 2022; 11:jcm11216246. [PMID: 36362474 PMCID: PMC9654330 DOI: 10.3390/jcm11216246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard for the antithrombotic management of patients with an acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Implementation of intensified or prolonged DAPT regimens has proven to lower the risk of ischemic events but at the expense of increased bleeding. Importantly, bleeding is a predictor of poor prognosis. Risk stratification and selection of tailored antiplatelet strategies to maximize the net clinical benefit in individual patients with ACS or undergoing PCI is therefore potentially beneficial. Recently, novel approaches including DAPT de-escalation or escalation have been proposed as possible alternatives to standard DAPT. These strategies, which are generally based on patient's risk profile, genetics, and/or platelet function have been proposed to offer more tailored treatments in patients with ACS or PCI, with the ultimate goal of providing adequate ischemic protection while mitigating the risk of bleeding. This review summarizes the available evidence on DAPT de-escalation or escalation (both guided and unguided) and discusses the practical implications of these strategies in the contemporary management of patients with ACS and/or undergoing PCI.
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Yamani N, Unzek S, Mankani MH, Almas T, Musheer A, Qamar H, Farooq S, Shahnawaz W, Fatima K, Figueredo V, Mookadam F. Does individualized guided selection of antiplatelet therapy improve outcomes after percutaneous coronary intervention? A systematic review and meta-analysis. Ann Med Surg (Lond) 2022; 79:103964. [PMID: 35860051 PMCID: PMC9289299 DOI: 10.1016/j.amsu.2022.103964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background The potential benefits of individualized guided selection of antiplatelet therapy over standard antiplatelet therapy in improving outcomes in patients undergoing percutaneous coronary intervention (PCI) have not been established. Therefore, we pooled evidence from available clinical trials to assess the effectiveness by comparing the two regimens in patients undergoing PCI. Methods We queried two electronic databases, MEDLINE and Cochrane CENTRAL, from their inception to April 20, 2021 for published randomized controlled trials in any language that compared guided antiplatelet therapy, using either genetic testing or platelet function testing, versus standard antiplatelet therapy in patients undergoing PCI. The results from trials were presented as risk ratios (RRs) with 95% confidence intervals (CIs) and were pooled using a random-effects model. Results Eleven eligible studies consisting of 18,465 patients undergoing PCI were included. Pooled results indicated that guided antiplatelet therapy, compared to standard therapy, was associated with a significant reduction in the incidence of MACE [RR 0·78, 95% CI (0·62–0·99), P = 0·04], MI [RR 0·73, 95% CI (0·56–0.96), P = 0·03], ST [RR 0·66, 95% CI (0·47–0.94), P = 0·02], stroke [RR 0·71, 95% CI (0·50–1.00), P = 0·05], and minor bleeding [RR 0·78, 95% CI (0·66–0.91), P = 0·003]. Conclusions Individualized guided selection of antiplatelet therapy significantly reduced the incidence of MACE, MI, ST, stroke, and minor bleeding in adult patients when compared with standard antiplatelet therapy. Our findings support the implementation of genetic and platelet function testing to select the most beneficial antiplatelet agent. Benefits of individualized guided selection of antiplatelet therapy over standard antiplatelet therapy in improving outcomes in patients undergoing percutaneous coronary intervention (PCI) have not been established. Guided therapy, consisting of either genetic testing or platelet function testing, can identify patients with this genetic variation allowing clinicians to provide modified and alternative treatment strategies and prescribe optimal antiplatelet agents. Individualized guided selection of antiplatelet therapy reduced the incidence of MACE, MI, ST, stroke, and minor bleeding in adult patients when compared with standard antiplatelet therapy. Can be more cost-effective than medication cost for every stroke, in-stent thrombosis, or MI case that needs hospitalization requiring more imaging and tests which can increase the total cost of treatment.
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Weintraub D, Posavi M, Fontanillas P, Tropea TF, Mamikonyan E, Suh E, Trojanowski JQ, Cannon P, Van Deerlin VM, Chen‐Plotkin AS. Genetic prediction of impulse control disorders in Parkinson's disease. Ann Clin Transl Neurol 2022; 9:936-949. [PMID: 35762106 PMCID: PMC9268896 DOI: 10.1002/acn3.51569] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To develop a clinico-genetic predictor of impulse control disorder (ICD) risk in Parkinson's disease (PD). METHODS In 5770 individuals from three PD cohorts (the 23andMe, Inc.; the University of Pennsylvania [UPenn]; and the Parkinson's Progression Markers Initiative [PPMI]), we used a discovery-replication strategy to develop a clinico-genetic predictor for ICD risk. We first performed a Genomewide Association Study (GWAS) for ICDs anytime during PD in 5262 PD individuals from the 23andMe cohort. We then combined newly discovered ICD risk loci with 13 ICD risk loci previously reported in the literature to develop a model predicting ICD in a Training dataset (n = 339, from UPenn and PPMI cohorts). The model was tested in a non-overlapping Test dataset (n = 169, from UPenn and PPMI cohorts) and used to derive a continuous measure, the ICD-risk score (ICD-RS), enriching for PD individuals with ICD (ICD+ PD). RESULTS By GWAS, we discovered four new loci associated with ICD at p-values of 4.9e-07 to 1.3e-06. Our best logistic regression model included seven clinical and two genetic variables, achieving an area under the receiver operating curve for ICD prediction of 0.75 in the Training and 0.72 in the Test dataset. The ICD-RS separated groups of PD individuals with ICD prevalence of nearly 40% (highest risk quartile) versus 7% (lowest risk quartile). INTERPRETATION In this multi-cohort, international study, we developed an easily computed clinico-genetic tool, the ICD-RS, that substantially enriches for subgroups of PD at very high versus very low risk for ICD, enabling pharmacogenetic approaches to PD medication selection.
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Affiliation(s)
- Daniel Weintraub
- Department of Psychiatry Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
- Department of Neurology Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
- Parkinson’s Disease Research, Education and Clinical Center (PADRECC) Philadelphia Veterans Affairs Medical Center Philadelphia Pennsylvania USA
| | - Marijan Posavi
- Department of Neurology Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | | | - Thomas F. Tropea
- Department of Neurology Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Eugenia Mamikonyan
- Department of Psychiatry Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Eunran Suh
- Department of Pathology and Laboratory Medicine Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - John Q. Trojanowski
- Department of Pathology and Laboratory Medicine Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | | | - Vivianna M. Van Deerlin
- Department of Pathology and Laboratory Medicine Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
| | - Alice S. Chen‐Plotkin
- Department of Neurology Perelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania USA
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Patti G, Grisafi L, Spinoni E, Rognoni A, Mennuni MG. Safety and efficacy of selective, clopidogrel-based strategies in acute coronary syndrome: a study-level meta-analysis. Thromb Haemost 2022; 122:1732-1743. [PMID: 35436797 DOI: 10.1055/a-1827-8041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To investigate outcome with selective, clopidogrel-based therapies vs conventional treatment in patients undergoing percutaneous coronary intervention (PCI), especially for acute coronary syndrome. BACKGROUND Safety and efficacy of alternative, selective, clopidogrel-based therapies after PCI are not robustly established. METHODS We performed a study-level meta-analysis on six randomized trials investigating selective clopidogrel-based therapies (three on unguided de-escalation, N=3,473; three on guided clopidogrel therapy, N=7,533). Control groups received ticagrelor or prasugrel treatment. Main endpoints were major bleeding, any bleeding, major adverse cardiovascular events (MACE) and net clinical endpoint. RESULTS The incidence of major bleeding and MACE was similar in the selective, clopidogrel-based therapy vs conventional treatment arm (OR 0·72, 95% CI 0·51-1·01, p=0·06; OR 0·93, 0·72-1·20, p=0·58; respectively). The rates of any bleeding were lower in the selective, clopidogrel-based therapy vs conventional treatment group (OR 0·57, 0·40-0·80, p=0·001); this greater safety was significant for unguided de-escalation (OR 0·43, 0·32-0·58, p=0·00001) and non-significant for guided clopidogrel therapy (OR 0·72, 0·51-1·02, p=0·07; p for interaction 0·03). The incidence of the net clinical endpoint was fewer in the selective, clopidogrel-based therapy vs conventional treatment arm (OR 0·59, 0·41-0·85, p=0·004); this benefit was significant for unguided de-escalation (OR 0·50, 0·39-0·64, p<0·00001) and non-significant for guided clopidogrel therapy (OR 0·85, 0·62-1·16, p=0·30; p for interaction 0·01). CONCLUSIONS As compared with prasugrel/ticagrelor treatment, alternative, selective, clopidogrel-based approaches provide a similar protection from cardiovascular events, reduce the risk of any bleeding and are associated with a greater net benefit. These beneficial effects were prevalent with unguided de-escalation to clopidogrel.
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Affiliation(s)
- Giuseppe Patti
- Chair of Cardiology, University of Eastern Piedmont Amedeo Avogadro School of Medicine, RM, Italy
| | - Leonardo Grisafi
- University of Eastern Piedmont Amedeo Avogadro School of Medicine, Novara, Italy
| | - Enrico Spinoni
- Thoracic-Cardio-VAscular, University of Eastern Piedmont Amedeo Avogadro School of Medicine, Novara, Italy
| | - Andrea Rognoni
- Azienda Ospedaliero-Universitaria Maggiore della Carita, Novara, Italy
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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13
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Al-abcha A, Radwan Y, Blais D, Mazzaferri EL, Boudoulas KD, Essa EM, Gumina RJ. Genotype-Guided Use of P2Y12 Inhibitors: A Review of Current State of the Art. Front Cardiovasc Med 2022; 9:850028. [PMID: 35402528 PMCID: PMC8983962 DOI: 10.3389/fcvm.2022.850028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
The pharmacodynamics of the purinergic receptor type Y, subtype 12 (P2Y12) inhibitors has evolved. Our understanding of the metabolism of P2Y12 inhibitors has revealed polymorphisms that impact drug metabolism and antiplatelet efficacy, leading to genetic testing guided therapy. In addition, assays of platelet function and biochemistry have provided insight into our understanding of the efficacy of "antiplatelet" therapy, identifying patients with high or low platelet reactivity on P2Y12 therapy. Despite the data, the implementation of these testing modalities has not gained mainstream adoption across hospital systems. Given differences in potency between the three clinically available P2Y12 inhibitors, the balance between thrombotic and bleeding complications must be carefully considered, especially for the large proportion of patients at higher risk for bleeding. Here we review the current data for genetic and functional testing, risk assessment strategies, and guidelines for P2Y12 inhibitors guided therapy.
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Affiliation(s)
- Abdullah Al-abcha
- Division of Internal Medicine, Department of Medicine, Michigan State University, East Lansing, MI, United States
| | - Yasser Radwan
- Division of Internal Medicine, Department of Medicine, Michigan State University, East Lansing, MI, United States
| | - Danielle Blais
- Division of Cardiology, Department of Medicine, Ohio State University, Columbus, OH, United States
| | - Ernest L. Mazzaferri
- Division of Cardiology, Department of Medicine, Ohio State University, Columbus, OH, United States
| | | | - Essa M. Essa
- Division of Cardiology, Department of Medicine, Mount Carmel Healthcare, Columbus, OH, United States
| | - Richard J. Gumina
- Division of Cardiology, Department of Medicine, Ohio State University, Columbus, OH, United States
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14
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Lee G, Varughese LA, Conway L, Stojinski C, Ashokkumar S, Monono K, Matthai W, Kolansky DM, Giri J, Tuteja S. Attitudes toward pharmacogenetics in patients undergoing CYP2C19 testing following percutaneous coronary intervention. Per Med 2022; 19:93-101. [PMID: 34984913 DOI: 10.2217/pme-2021-0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aim: Patient knowledge and attitudes toward pharmacogenetic (PGx) testing may impact adoption of clinical testing. Methods: Questionnaires regarding knowledge, attitudes and ethics of PGx testing were distributed to 504 patients enrolled in the ADAPT study conducted at two urban hospitals in Philadelphia, Pennsylvania, USA. Responses were assessed using multivariable logistic regression. Results: 311 completed the survey (62% response rate). 74% were unaware of PGx testing, but 79% indicated using PGx results to predict medication efficacy was important. In a multivariable model, higher education level (p = 0.031) and greater genetics knowledge (p < 0.001) were associated with more positive attitudes toward PGx testing. Conclusion: Greater patient knowledge of genetics was associated with a more positive attitude toward PGx testing, indicating that educational strategies aimed at increasing genetics knowledge may enhance adoption of PGx testing in the clinic.
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Affiliation(s)
- Grace Lee
- Department of Genetic Counseling, Arcadia University, Glenside, PA, USA
| | - Lisa A Varughese
- Division of Translational Medicine & Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura Conway
- Department of Genetic Counseling, Arcadia University, Glenside, PA, USA.,Division of Translational Medicine & Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Carol Stojinski
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Sandhya Ashokkumar
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Karen Monono
- Division of Translational Medicine & Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - William Matthai
- Cardiovascular Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniel M Kolansky
- Cardiovascular Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jay Giri
- Cardiovascular Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center & the Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sony Tuteja
- Division of Translational Medicine & Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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15
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Malik AH, Gupta R, Chakraborty S, Mahajan P, Bandyopadhyay D, Yandrapalli S, Zaid S, Sreenivasan J, Chaturvedi A, Mehta SS, Vyas AV, Patel NC, Combs WG, Ahmad H. Effect of genotype guided oral P2Y12 inhibitor selection after percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 41:115-121. [DOI: 10.1016/j.carrev.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/11/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022]
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16
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Hajek C, Hutchinson AM, Galbraith LN, Green RC, Murray MF, Petry N, Preys CL, Zawatsky CLB, Zoltick ES, Christensen KD. Improved provider preparedness through an 8-part genetics and genomic education program. Genet Med 2022; 24:214-224. [PMID: 34906462 PMCID: PMC9121992 DOI: 10.1016/j.gim.2021.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/25/2021] [Accepted: 08/13/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Large-scale genetics education appropriate for general practice providers is a growing priority. We describe the content and impact of a mandatory system-wide program implemented at Sanford Health. METHODS The Imagenetics Initiative at Sanford Health developed a 2-year genetics education program with quarterly web-based modules that were mandatory for all physicians and advanced practice providers. Scores of 0 to 5 were calculated for each module on the basis of the number of objectives that the participants reported as fulfilled. In addition, the participants completed surveys before starting and after finishing the education program, which included a 7-item measure scored 7 to 28 on the perceived preparedness to practice genetics. RESULTS Between 2252 and 2822 Sanford Health employees completed each of the 8 quarterly education modules. The ratings were highest for the module about using genomics to improve patient management (mean score = 4.3) and lowest for the module about different types of genetic tests and specialists. The mean perceived preparedness scores increased from 15.7 at pre-education to 19.1 at post-education (P < .001). CONCLUSION Web-based genetics education was highly effective in increasing health care providers' confidence about using genetics. Both comfort with personal knowledge and confidence regarding access to the system's genomic medicine experts increased significantly. The results demonstrate how scalable approaches can improve provider preparedness.
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Affiliation(s)
- Catherine Hajek
- Sanford Health Imagenetics, Sioux Falls, SD; Sanford School of Medicine, University of South Dakota, Sioux Falls, SD.
| | | | - Lauren N Galbraith
- Department of Population Medicine, Center for Healthcare Research in Pediatrics (CHERP), Harvard Pilgrim Health Care Institute, Boston, MA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Department of Medicine, Harvard Medical School, Boston, MA; Ariadne Labs, Boston, MA
| | | | - Natasha Petry
- Sanford Health Imagenetics, Fargo, ND; Department of Pharmacy Practice, School of Pharmacy, North Dakota State University, Fargo, ND
| | - Charlene L Preys
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA; MGH Institute of Health Professions, Boston, MA
| | - Carrie L B Zawatsky
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Ariadne Labs, Boston, MA
| | - Emilie S Zoltick
- Department of Population Medicine, Center for Healthcare Research in Pediatrics (CHERP), Harvard Pilgrim Health Care Institute, Boston, MA
| | - Kurt D Christensen
- Department of Population Medicine, Center for Healthcare Research in Pediatrics (CHERP), Harvard Pilgrim Health Care Institute, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA; Department of Population Medicine, Harvard Medical School, Boston, MA
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17
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Hoffecker G, Kanter GP, Xu Y, Matthai W, Kolansky DM, Giri J, Tuteja S. Interventional cardiologists' attitudes towards pharmacogenetic testing and impact on antiplatelet prescribing decisions. Per Med 2021; 19:41-49. [PMID: 34881641 DOI: 10.2217/pme-2021-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To determine if interventional cardiologists' knowledge and attitudes toward pharmacogenetic (PGx) testing influenced their antiplatelet prescribing decisions in response to CYP2C19 results. Materials & methods: Surveys were administered prior to participating in a randomized trial of CYP2C19 testing. Associations between baseline knowledge/attitudes and agreement with the genotype-guided antiplatelet recommendations were determined using multivariable logistic regression. Results: 50% believed that PGx testing would be valuable to predict medication toxicity or efficacy. 64% felt well informed about PGx testing and its therapeutic application. However, PGx experience, knowledge, nor attitudes were significantly associated with agreement to genotype-guided antiplatelet recommendations. Conclusion: Cardiologists' knowledge and attitudes were not associated with CYP2C19-guided antiplatelet prescribing, but larger studies should be done to confirm this finding.
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Affiliation(s)
- Glenda Hoffecker
- Division of Translational Medicine & Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Genevieve P Kanter
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Yao Xu
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - William Matthai
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Daniel M Kolansky
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Jay Giri
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA.,Penn Cardiovascular Outcomes, Quality, & EvaluativeResearch Center, Leonard Davis Institute of Health Economics, University ofPennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Sony Tuteja
- Division of Translational Medicine & Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
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18
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Parcha V, Heindl BF, Li P, Kalra R, Limdi NA, Pereira NL, Arora G, Arora P. Genotype-Guided P2Y
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Inhibitor Therapy After Percutaneous Coronary Intervention: A Bayesian Analysis. Circ Genom Precis Med 2021; 14:e003353. [DOI: 10.1161/circgen.121.003353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Among patients receiving percutaneous coronary intervention (PCI), the role of a genotype-guided approach for antiplatelet therapy compared with usual care is unclear. We conducted a Bayesian analysis of the entire TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention) randomized clinical trial population to evaluate the effect of the genotype-guided antiplatelet therapy post-PCI compared with the usual care on the risk of major adverse cardiovascular events (MACE).
Methods:
The primary outcome for our study was the composite of MACE (myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included cardiovascular death, stroke, myocardial infarction, stent thrombosis, and major/minor bleeding. Bayesian modeling was used to estimate the probability of clinical benefit of genotype-guided therapy using (1) noninformative priors (ie, analyzing the TAILOR-PCI trial) and (2) informative priors derived from the ADAPT, POPular Genetics, IAC-PCI, and PHARMCLO trials (ie, analyzing TAILOR-PCI trial in the context of prior evidence). Risk ratio (RR: ratio of cumulative outcome incidence between genotype-guided and conventional therapy group) and 95% credible interval (CrI) were estimated for the study outcomes, and probability estimates for RR <1 were computed.
Results:
Using noninformative priors, in TAILOR-PCI the RR for MACE was 0.78 (95% CrI, 0.55–1.07) in genotype-guided therapy after PCI, and the probability of RR <1 was 94%. Using noninformative priors, the probability of RR <1 for cardiovascular death (RR, 0.95 [95% CrI, 0.52–1.74]), stroke (RR, 0.68 [95% CrI, 0.44–1.06]), myocardial infarction (RR, 0.84 [95% CrI, 0.37–1.89]), stent thrombosis (RR, 0.75 [95% CrI, 0.37–1.45]), and major or minor bleeding (RR, 1.22 [95% CrI, 0.84–1.77]) were 57%, 96%, 67%, 81%, and 15%, respectively. Using informative priors, the posterior probability of RR <1 for MACE, from genotype-guided therapy, was 99% (RR, 0.69 [95% CrI, 0.57–0.84]). Using informative priors, the posterior probability of RR <1 for cardiovascular death (RR, 0.86 [95% CrI, 0.61–1.19]), stroke (RR, 0.69 [95% CrI, 0.48–0.99]), myocardial infarction (RR:0.56 [95% CrI, 0.40–0.78]), stent thrombosis (RR, 0.59 [95% CrI, 0.38–0.94]), and major or minor bleeding (RR, 0.84 [95% CrI, 0.70–0.99]) were 81%, 99%, 99%, 99%, and 99%, respectively.
Conclusions:
Bayesian analysis of the TAILOR-PCI trial provides clinically meaningful data on the posterior probability of reducing MACE using genotype-guided P2Y
12
inhibitor therapy after PCI.
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Affiliation(s)
- Vibhu Parcha
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
| | - Brittain F. Heindl
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
| | - Peng Li
- School of Nursing (P.L.), University of Alabama at Birmingham
| | - Rajat Kalra
- Cardiology Division, University of Minnesota, MN (R.K.)
| | - Nita A. Limdi
- Department of Neurology (N.A.L.), University of Alabama at Birmingham
- Department of Epidemiology (N.A.L.), University of Alabama at Birmingham
| | - Naveen L. Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.L.P.)
- William J. von Liebig Center for Transplantation and Clinical Regeneration (N.L.P.), Mayo Clinic, Rochester, MN
- Department of Molecular Pharmacology and Experimental Therapeutics (N.L.P), Mayo Clinic, Rochester, MN
| | - Garima Arora
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
| | - Pankaj Arora
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, AL (P.A.)
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19
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. Utility of a pharmacogenetic-driven algorithm in guiding dual antiplatelet therapy for patients undergoing coronary drug-eluting stent implantation in China. Eur J Clin Pharmacol 2021; 78:215-225. [PMID: 34636928 DOI: 10.1007/s00228-021-03224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
PURPOSES The POPular Risk Score (PRiS), a pharmacogenetic-driven algorithm consisting of CYP2C19 genotype, platelet reactivity, and clinical risk factors, is developed to evaluate ischemic risk and guide dual antiplatelet therapy (DAPT). This study aimed to evaluate the efficacy and safety of DAPT in accordance with the PRiS in patients undergoing drug-eluting stent (DES) implantation. METHODS A total of 1757 patients recruited in this cohort study were divided into four groups according to the PRiS and type of P2Y12 receptor inhibitor treatment at discharge. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and target vessel revascularization) during 1-year follow-up. The safety endpoints were defined by Bleeding Academic Research Consortium (BARC) criteria as major bleeding (BARC 3a, 3b, 3c, and 5) and clinically relevant bleeding (BARC 2, 3a, 3b, 3c, and 5). RESULTS Among 1046 patients with PRiS < 2 and 711 patients with PRiS ≥ 2, 34.2% and 38.3% of them were treated with ticagrelor, respectively. The PRiS ≥ 2 was an independent predictor for the 1-year incidence of MACE (HR(95%CI): 2.09 (1.37-3.20), p = 0.001). Multivariable Cox regression indicated that in the PRiS ≥ 2 group, ticagrelor was superior to clopidogrel in reducing the risk of MACE (HR(95%CI): 0.53 (0.29-0.98), p = 0.042), without increasing the bleeding risk. On the other hand, in the PRiS < 2 group, clopidogrel treatment was related to a remarkably lower rate of BARC class ≥ 2 bleeding (HR(95%CI): 0.39 (0.20-0.72), p = 0.003), but comparable incidences of MACE and BARC class ≥ 3 bleeding during 1-year follow-up. Similar associations between P2Y12 receptor inhibitors and 1-year endpoints in the PRiS < 2 and PRiS ≥ 2 group could also be identified in propensity score-weighted analysis and propensity score-matched analysis. CONCLUSION Tailored DAPT based on the PRiS could assist in improving the prognosis of patients undergoing DES implantation. Further randomized controlled trials are required to provide more evidence for PRiS-guided DAPT.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China.
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20
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Moulias A, Papageorgiou A, Alexopoulos D. Platelet Function Testing and Genotyping for Tailoring Treatment in Complex PCI Patients. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is considered the cornerstone of treatment in patients who have undergone percutaneous coronary intervention (PCI). Patients with complex PCI (C-PCI) constitute a special PCI subpopulation, characterized by increased ischemic risk. Identifying the optimal DAPT strategy is often challenging and remains controversial in this setting. In an attempt to balance ischemic and bleeding risks in C-PCI patients receiving DAPT, treatment individualization regarding potency and duration has evolved as a feasible approach. Platelet function testing and genotyping have been evaluated in several trials with conflicting and mostly neutral results. The aim of this review is to critically appreciate the role of these tools for antiplatelet treatment tailoring specifically in C-PCI patients. Because existing evidence is limited, dedicated future studies are warranted to elucidate the utility of platelet function testing and genotyping in C-PCI.
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Affiliation(s)
- Athanasios Moulias
- Department of Cardiology, General University Hospital of Patras, Patras, Greece
| | | | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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21
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Galli M, Franchi F, Rollini F, Cavallari LH, Capodanno D, Crea F, Angiolillo DJ. Genetic testing in patients undergoing percutaneous coronary intervention: rationale, evidence and practical recommendations. Expert Rev Clin Pharmacol 2021; 14:963-978. [PMID: 33993817 PMCID: PMC9008593 DOI: 10.1080/17512433.2021.1927709] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/06/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Clopidogrel is the most frequently utilized P2Y12 inhibitor and is characterized by broad interindividual response variability resulting in impaired platelet inhibition and increased risk of thrombotic complications in a considerable number of patients. The potent P2Y12 inhibitors, prasugrel and ticagrelor, can overcome this limitation but at the expense of an increased risk of bleeding. Genetic variations of the cytochrome P450 (CYP) 2 C19 enzyme, a key determinant in clopidogrel metabolism, have been strongly associated with clopidogrel response profiles prompting investigations of genetic-guided selection of antiplatelet therapy. AREAS COVERED The present manuscript focuses on the rationale for the use of genetic testing to guide the selection of platelet P2Y12 inhibitors among patients undergoing percutaneous coronary intervention (PCI). Moreover, a comprehensive appraisal of the available evidence and practical recommendations is provided. EXPERT COMMENTARY Implementation of genetic testing as a strategy to guide the selection of therapy can result in escalation (i.e. switching to prasugrel or ticagrelor) or de-escalation (i.e. switching to clopidogrel) of P2Y12 inhibiting therapy. Most recent investigations support the clinical benefit of a genetic guided selection of antiplatelet therapy in patients undergo PCI. Integrating the results of genetic testing with clinical and procedural variables represents a promising strategy for a precision medicine approach for the selection of antiplatelet therapy among patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, University of Florida, Gainesville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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22
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Jafrin S, Naznin NE, Reza MS, Aziz MA, Islam MS. Risk of stroke in CYP2C19 LoF polymorphism carrier coronary artery disease patients undergoing clopidogrel therapy: An ethnicity-based updated meta-analysis. Eur J Intern Med 2021; 90:49-65. [PMID: 34092486 DOI: 10.1016/j.ejim.2021.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/20/2021] [Accepted: 05/16/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antiplatelet agent clopidogrel has been widely used for stroke management for many years, although resistance to clopidogrel may increase the chance of stroke recurrence. CYP2C19 loss-of-function (LoF) polymorphism is assumed to be responsible for the poor metabolism of clopidogrel that ultimately turns to resistance. Previous publications could not provide firm evidence due to highly conflicting and heterogeneous outcomes. AIM To get clear evidence from an updated meta-analysis on CYP2C19 LoF polymorphism association with stroke risk in clopidogrel treated patients, this study has been performed. METHODS We conducted a meta-analysis with 72 selected studies from authentic databases, including 40,035 coronary artery disease patients treated with clopidogrel. RESULTS This analysis showed that the worldwide carrier of one or more CYP2C19 LoF alleles had a significantly higher risk of stroke and composite events than the non-LoF carriers (RR=1.78, 95% CI=1.52-2.07, p<0.00001 and RR=1.39, 95% CI=1.26-1.54, p<0.00001, respectively). Besides, subgroup analysis showed that Asian CYP2C19 LoF carriers had a significantly increased risk of stroke (RR=1.91, 95% CI=1.60-2.28, p<0.00001) while the risk of composite events was significantly higher in all ethnic populations (Asian: RR=1.58, 95% CI=1.32-1.89, p<0.00001; Caucasian: RR=1.27, 95% CI=1.08-1.50, p=0.003; Hispanic and others: RR=1.21, 95% CI=1.09-1.34, p=0.0003). CONCLUSION Our meta-analysis confirmed that the presence of CYP2C19 LoF alleles increases the risk of stroke and composite events recurrence in the worldwide population, especially in Asians undergoing clopidogrel treatment. Alternative antiplatelet therapy should be investigated thoroughly for the intermediate and poor metabolizers.
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Affiliation(s)
- Sarah Jafrin
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Nura Ershad Naznin
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Md Sharif Reza
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Md Abdul Aziz
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh
| | - Mohammad Safiqul Islam
- Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur 3814, Noakhali, Bangladesh.
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David V, Fylan B, Bryant E, Smith H, Sagoo GS, Rattray M. An Analysis of Pharmacogenomic-Guided Pathways and Their Effect on Medication Changes and Hospital Admissions: A Systematic Review and Meta-Analysis. Front Genet 2021; 12:698148. [PMID: 34394187 PMCID: PMC8362615 DOI: 10.3389/fgene.2021.698148] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/28/2021] [Indexed: 01/02/2023] Open
Abstract
Ninety-five percent of the population are estimated to carry at least one genetic variant that is discordant with at least one medication. Pharmacogenomic (PGx) testing has the potential to identify patients with genetic variants that puts them at risk of adverse drug reactions and sub-optimal therapy. Predicting a patient's response to medications could support the safe management of medications and reduce hospitalization. These benefits can only be realized if prescribing clinicians make the medication changes prompted by PGx test results. This review examines the current evidence on the impact PGx testing has on hospital admissions and whether it prompts medication changes. A systematic search was performed in three databases (Medline, CINAHL and EMBASE) to search all the relevant studies published up to the year 2020, comparing hospitalization rates and medication changes amongst PGx tested patients with patients receiving treatment-as-usual (TAU). Data extracted from full texts were narratively synthesized using a process model developed from the included studies, to derive themes associated to a suggested workflow for PGx-guided care and its expected benefit for medications optimization and hospitalization. A meta-analysis was undertaken on all the studies that report the number of PGx tested patients that had medication change(s) and the number of PGx tested patients that were hospitalized, compared to participants that received TAU. The search strategy identified 5 hospitalization themed studies and 5 medication change themed studies for analysis. The meta-analysis showed that medication changes occurred significantly more frequently in the PGx tested arm across 4 of 5 studies. Meta-analysis showed that all-cause hospitalization occurred significantly less frequently in the PGx tested arm than the TAU. The results show proof of concept for the use of PGx in prescribing that produces patient benefit. However, the review also highlights the opportunities and evidence gaps that are important when considering the introduction of PGx into health systems; namely patient involvement in PGx prescribing decisions, thus a better understanding of the perspective of patients and prescribers. We highlight the opportunities and evidence gaps that are important when considering the introduction of PGx into health systems.
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Affiliation(s)
- Victoria David
- Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom.,School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom.,Wolfson Centre for Applied Health Research, Bradford, United Kingdom
| | - Beth Fylan
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom.,Wolfson Centre for Applied Health Research, Bradford, United Kingdom.,Yorkshire and Humber Patient Safety Translational Research Centre, Bradford Institute of Health Research, Bradford, United Kingdom
| | - Eleanor Bryant
- Wolfson Centre for Applied Health Research, Bradford, United Kingdom.,Division of Psychology in the School of Social Sciences, University of Bradford, Bradford, United Kingdom
| | - Heather Smith
- Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
| | - Gurdeep S Sagoo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds In Vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Marcus Rattray
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom.,Wolfson Centre for Applied Health Research, Bradford, United Kingdom
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24
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Shi X, Zhang Y, Zhang Y, Zhang R, Lin B, Han J, Li W, Fang Z, Yan J, Wang Y, Zheng Z, Lv Y, Lin Y. Personalized Antiplatelet Therapy Based on CYP2C19 Genotypes in Chinese ACS Patients Undergoing PCI: A Randomized Controlled Trial. Front Cardiovasc Med 2021; 8:676954. [PMID: 34222372 PMCID: PMC8242578 DOI: 10.3389/fcvm.2021.676954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The clinical benefits of cytochrome P450 (CYP) 2C19 genotype-guided antiplatelet therapy in Asians remain unclear. In this study, we aimed to investigate the clinical outcomes of pharmacogenomic antiplatelet therapy in Chinese patients. Methods: Patients with acute coronary syndrome planning to undergo percutaneous coronary intervention were eligible for this study and were randomly divided into a genotype-guided treatment (GT) group and routine treatment (RT) group, with a ratio of 2:1. Patients in the GT group underwent CYP2C19 genotyping (*2 and *3 alleles), and the results were considered in selecting P2Y12 receptor inhibitors. Patients in the RT group were treated with P2Y12 receptor inhibitors according to their clinical characteristics. The primary endpoint was a composite of major adverse cardiovascular or cerebrovascular events (MACCE). The secondary endpoint was significant bleeding events. Results: Finally, 301 patients were enrolled; 75.1% were men and the mean age was 59.7 ± 9.8 years. In total, 281 patients completed the follow-up procedure. The primary endpoint occurred in 16 patients, 6 patients in the GT group and 10 in the RT group. The GT group showed lower MACCE rates than the RT group (6/189 vs. 10/92, 3.2 vs. 10.9%, hazard ratio: 0.281, 95% confidence interval: 0.102-0.773, P = 0.009). There was no statistically difference in significant bleeding events between the GT and RT groups (4.2 vs. 3.3%, hazard ratio: 1.315, 95% confidence interval: 0.349-4.956, P = 0.685). Conclusion: Personalized antiplatelet therapy that is based on CYP2C19 genotypes could decrease MACCE within a 12-month period in Chinese patients with acute coronary syndrome undergoing percutaneous coronary intervention. Clinical Trial Registration: http://www.chictr.org.cn, identifier: ChiCTR2000034352.
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Affiliation(s)
- Xiujin Shi
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yunnan Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Ru Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Baidi Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Jialun Han
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Wenzheng Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhenwei Fang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jialin Yan
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yifan Wang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Ze Zheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Lv
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
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25
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Cao D, Chandiramani R, Chiarito M, Claessen BE, Mehran R. Evolution of antithrombotic therapy in patients undergoing percutaneous coronary intervention: a 40-year journey. Eur Heart J 2021; 42:339-351. [PMID: 33367641 DOI: 10.1093/eurheartj/ehaa824] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/02/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
Since its introduction in 1977, percutaneous coronary intervention has become one of the most commonly performed therapeutic procedures worldwide. Such widespread diffusion, however, would have not been possible without a concomitant evolution of the pharmacotherapies associated with this intervention. Antithrombotic agents are fundamental throughout the management of patients undergoing coronary stent implantation, starting from the procedure itself to the long-term prevention of cardiovascular events. The last 40 years of interventional cardiology have seen remarkable improvements in both drug therapies and device technologies, which largely reflected a progressive understanding of the pathophysiological mechanisms of coronary artery disease, as well as procedure- and device-related adverse events. The purpose of this article is to provide an overview of the important milestones in antithrombotic pharmacology that have shaped clinical practice of today while also providing insights into knowledge gaps and future directions.
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Affiliation(s)
- Davide Cao
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Rishi Chandiramani
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Mauro Chiarito
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy.,Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Via Alessandro Manzoni 56, 20090 Rozzano, Milan, Italy
| | - Bimmer E Claessen
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Roxana Mehran
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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26
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Galli M, Benenati S, Capodanno D, Franchi F, Rollini F, D'Amario D, Porto I, Angiolillo DJ. Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Lancet 2021; 397:1470-1483. [PMID: 33865495 DOI: 10.1016/s0140-6736(21)00533-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/18/2021] [Accepted: 02/23/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Whether guided selection of antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) is effective in improving outcomes compared with standard antiplatelet therapy remains controversial. We assessed the safety and efficacy of guided versus standard selection of antiplatelet therapy in patients undergoing PCI. METHODS For this systematic review and meta-analysis, from Aug 20 to Oct 25, 2020, we searched MEDLINE (via PubMed), Cochrane, Embase, and Web of Science databases for randomised controlled trials and observational studies published in any language that compared guided antiplatelet therapy, by means of platelet function testing or genetic testing, versus standard antiplatelet therapy in patients undergoing PCI. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% CIs were used with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Coprimary endpoints were trial-defined primary major adverse cardiovascular events and any bleeding. Key secondary endpoints were all-cause death, cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and major and minor bleeding. This study is registered with PROSPERO (CRD42021215901). FINDINGS 3656 potentially relevant articles were screened. Our analysis included 11 randomised controlled trials and three observational studies with data for 20 743 patients. Compared with standard therapy, guided selection of antiplatelet therapy was associated with a reduction in major adverse cardiovascular events (RR 0·78, 95% CI 0·63-0·95, p=0·015) and reduced bleeding, although not statistically significant (RR 0·88, 0·77-1·01, p=0·069). Cardiovascular death (RR 0·77, 95% CI 0·59-1·00, p=0·049), myocardial infarction (RR 0·76, 0·60-0·96, p=0·021), stent thrombosis (RR 0·64, 0·46-0·89, p=0·011), stroke (RR 0·66, 0·48-0·91, p=0·010), and minor bleeding (RR 0·78, 0·67-0·92, p=0·0030) were reduced with guided therapy compared with standard therapy. Risks of all-cause death and major bleeding did not differ between guided and standard approaches. Outcomes varied according to the strategy used, with an escalation approach associated with a significant reduction in ischaemic events without any trade-off in safety, and a de-escalation approach associated with a significant reduction in bleeding, without any trade-off in efficacy. INTERPRETATION Guided selection of antiplatelet therapy improved both composite and individual efficacy outcomes with a favourable safety profile, driven by a reduction in minor bleeding, supporting the use of platelet function or genetic testing to optimise the choice of agent in patients undergoing PCI. FUNDING None.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy; Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stefano Benenati
- Department of Internal Medicine and Medical Specialties (DIMI) Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico Gaspare Rodolico-San Marco, University of Catania, Catania, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI) Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy; DICATOV Cardiothoracic and Vascular Department, San Martino Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Dominick J Angiolillo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
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27
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Nazir S, Ahuja KR, Virk HUH, Elzanaty A, Waheed TA, Changal KH, Wohlfarth K, Lakhter V, Grande RD, Eltahawy EA. A meta-analysis of efficacy and safety of genotype-guided versus standard of care treatment strategies in selecting antiplatelet therapy in patients with acute coronary syndrome. Catheter Cardiovasc Interv 2021; 97:788-794. [PMID: 32243053 DOI: 10.1002/ccd.28860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 03/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies have shown similar rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients, treated with P2Y12 inhibitors based on genotype guidance compared to standard treatment. However, given lower than expected event rates, these studies were underpowered to assess hard outcomes. We sought to systematically analyze this evidence using pooled data from multiple studies. METHODS Electronic databases were searched for studies of ACS patients that underwent genotype-guided treatment (GGT) with P2Y12 inhibitors versus standard of care treatment (SCT). Studies with a minimum follow-up of 12 months were included. Rate of MACE (defined as a composite of cardiovascular [CV] mortality, nonfatal myocardial infarction [MI], and nonfatal stroke) was the primary outcome. Secondary outcomes were individual components of MI, CV mortality, ischemic stroke, stent thrombosis, and major bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis. RESULTS A total of 4,095 patients (2007 in the GGT and 2088 in the SCT group were analyzed from three studies). Significantly lower odds of MACE (6.0 vs. 9.2%; OR: 0.63, 95% CI: 0.50-0.80, p < .001, I2 = 0%) and MI (3.3 vs. 5.45%; OR: 0.63; CI 0.41-0.96; p = .03; I2 = 46%) were noted in the GGT group compared to SCT. No significant difference was noted with respect to CV and other secondary outcomes. CONCLUSION In patients with ACS, genotype-guided initiation of P2Y12 inhibitors was associated with lower odds of MACE and similar bleeding risk in comparison to SCT.
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Affiliation(s)
- Salik Nazir
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Keerat R Ahuja
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hafeez U H Virk
- Department of Cardiology, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Ahmed Elzanaty
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Tayyab A Waheed
- Department of Medicine, Reading Hospital-Tower Health System, West Reading, Pennsylvania, USA
| | - Khalid H Changal
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
| | | | - Vladimir Lakhter
- Department of Cardiology, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Ehab A Eltahawy
- Department of Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
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28
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Zhang Y, Shi XJ, Peng WX, Han JL, Lin BD, Zhang R, Zhang YN, Yan JL, Wei JJ, Wang YF, Chen SW, Nan N, Fang ZW, Zeng Y, Lin Y. Impact of Implementing CYP2C19 Genotype-Guided Antiplatelet Therapy on P2Y 12 Inhibitor Selection and Clinical Outcomes in Acute Coronary Syndrome Patients After Percutaneous Coronary Intervention: A Real-World Study in China. Front Pharmacol 2021; 11:582929. [PMID: 33551797 PMCID: PMC7854467 DOI: 10.3389/fphar.2020.582929] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/21/2020] [Indexed: 12/04/2022] Open
Abstract
Background: CYP2C19 loss-of-function (LOF) alleles reduce the effectiveness of clopidogrel in patients undergoing percutaneous coronary intervention for acute coronary syndrome. However, the clinical impact of implementing CYP2C19 gene-guided pharmacotherapy is unclear, especially among the Chinese population. The purpose of this study was to evaluate P2Y12 receptor inhibitor selection and clinical outcomes upon implementation of CYP2C19 genotype-guided pharmacotherapy in current clinical practice. Methods: This was a single-center observational cohort study. Adult percutaneous coronary intervention patients who received CYP2C19 genetic testing (*2, *3, *17 alleles) were included. Ticagrelor was recommended for patients with a LOF allele. Factors related to P2Y12 inhibitor selection were determined by logistic regression. The primary endpoint was major cardiac or cerebrovascular adverse events (MACCE) within 12 months. MACCE and clinically significant bleeding events (BARC ≥2) in the LOF-clopidogrel group, non-LOF-clopidogrel group, and non-LOF-ticagrelor group were compared with those in the LOF-ticagrelor group. The inverse probability of treatment weighting (IPTW) was adjusted in a Cox regression analysis to eliminate confounding factors. Results: Among 1,361 patients, 826 (60.7%) had a LOF allele. Patients with a LOF allele were more likely to be prescribed ticagrelor (multivariate-adjusted OR 1.349; 95% CI 1.040 to 1.751; p = 0.024). The MACCE rate was higher in the LOF-clopidogrel group than in the LOF-ticagrelor group (7.8 vs. 4.0%; log-rank p = 0.029; IPTW-adjusted HR 2.138; 95% CI 1.300–3.515). Compared with the LOF-ticagrelor group, the non-LOF-clopidogrel group showed no significant difference in MACCE rate (5.8 vs. 4.0%; log-rank p = 0.272; IPTW-adjusted HR 1.531; 95% CI 0.864–2.714). Among the patients treated with ticagrelor, there was no significant difference in the MACCE rate between the LOF group and non-LOF group (4.3 vs. 4.0%; log-rank p = 0.846; IPTW-adjusted HR 1.184; 95% CI 0.582–2.410). There was no significant difference in the incidence of clinically significant bleeding events among the four groups. Conclusion: This study confirms that efficiently returned CYP2C19 genotype results did partially guide cardiologists to prescribe ticagrelor for patients with a LOF allele, and that clopidogrel had a higher risk of MACCE than ticagrelor in these patients, which provides support for the implementation of CYP2C19 gene-guided antiplatelet therapy in clinical practice.
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Affiliation(s)
- Yi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiu-Jin Shi
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen-Xing Peng
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jia-Lun Han
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bai-Di Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ru Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yun-Nan Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jia-Lin Yan
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Juan-Juan Wei
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Fan Wang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Su-Wei Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Nan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhen-Wei Fang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yong Zeng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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29
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Zhang H, Xiang Q, Liu Z, Mu G, Xie Q, Zhou S, Ma L, Wang Z, Hu K, Wang Z, Cui Y. Genotype-guided antiplatelet treatment versus conventional therapy: A systematic review and meta-analysis. Br J Clin Pharmacol 2020; 87:2199-2215. [PMID: 33140858 DOI: 10.1111/bcp.14637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/29/2022] Open
Abstract
AIM This meta-analysis was carried out to explore if a personalized antiplatelet strategy based on genotyping is superior to conventional therapy. METHODS PubMed, Web of Science, EMBASE and the Cochrane Library were searched from the inception of each database to 5 May 2020. Studies reporting endpoints in genotype-guided treatment group and conventional treatment group were included. The endpoint results were presented as the risk ratio (RR), with 95% confidence interval (CI). RESULTS A total of 10 561 patients from 16 studies (eight randomized controlled trials [RCT] and eight cohort studies) were included in the meta-analysis. The rates of major adverse cardiovascular events (MACE), stent thrombosis and myocardial infarction (MI) were significantly lower in the genotype-guided group than in the conventional treatment group (RR 0.56, 95% CI 0.44-0.73, P < .0001; RR 0.40, 95% CI 0.24-0.67, P = .0005; RR 0.45, 95% CI 0.35-0.58, P < .00001, respectively). A significant difference was found between the two groups in major bleeding (RR 0.73, 95% CI 0.55-0.98, P = .04), which was not robust after sensitivity analysis. CONCLUSION Genotype-guided antiplatelet treatment could decrease the risk of MACE, stent thrombosis and MI in patients with coronary artery disease or undergoing percutaneous coronary intervention, without increasing the risk of bleeding over a long follow-up period. The decreased risk of efficacy outcomes was more obvious in cohort studies. Well-organized RCTs and clinical trials are required to verify the benefit of genotype-guided therapy.
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Affiliation(s)
- Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
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30
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Nazir S, Ahuja KR, Elzanaty A, Patel NJ, Mahmood M, Changal K, Macciocca M, Gupta R. Meta-Analysis of the Efficacy and Safety of Genotype-Guided Strategy for Selection of P2Y 12 Inhibitors in Coronary Artery Disease. Am J Cardiol 2020; 136:168-170. [PMID: 32961111 DOI: 10.1016/j.amjcard.2020.09.023] [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: 09/02/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Salik Nazir
- Division of Cardiology, University of Toledo Medical Center, Toledo, Ohio
| | - Keerat Rai Ahuja
- Division of Cardiology, Reading Hospital-Tower Health System, West Reading, Pennsylvania
| | - Ahmed Elzanaty
- Department of Medicine, University of Toledo Medical Center, Toledo, Ohio
| | - Neha J Patel
- Department of Medicine, University of Toledo Medical Center, Toledo, Ohio
| | - Muhammad Mahmood
- Department of Medicine, University of Toledo Medical Center, Toledo, Ohio
| | - Khalid Changal
- Division of Cardiology, University of Toledo Medical Center, Toledo, Ohio
| | - Michael Macciocca
- Division of Cardiology, Reading Hospital-Tower Health System, West Reading, Pennsylvania
| | - Rajesh Gupta
- Division of Cardiology, University of Toledo Medical Center, Toledo, Ohio.
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31
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Lee CR, Thomas CD, Beitelshees AL, Tuteja S, Empey PE, Lee JC, Limdi NA, Duarte JD, Skaar TC, Chen Y, Cook KJ, Coons JC, Dillon C, Franchi F, Giri J, Gong Y, Kreutz RP, McDonough CW, Stevenson JM, Weck KE, Angiolillo DJ, Johnson JA, Stouffer GA, Cavallari LH. Impact of the CYP2C19*17 Allele on Outcomes in Patients Receiving Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2020; 109:705-715. [PMID: 32897581 DOI: 10.1002/cpt.2039] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/18/2020] [Indexed: 01/03/2023]
Abstract
Genotyping for CYP2C19 no function alleles to guide antiplatelet therapy after percutaneous coronary intervention (PCI) improves clinical outcomes. Although results for the increased function CYP2C19*17 allele are also reported, its clinical relevance in this setting remains unclear. A collaboration across nine sites examined antiplatelet therapy prescribing and clinical outcomes in 3,342 patients after implementation of CYP2C19-guided antiplatelet therapy. Risk of major atherothrombotic and bleeding events over 12 months after PCI were compared across cytochrome P450 2C19 isozyme (CYP2C19) metabolizer phenotype and antiplatelet therapy groups by proportional hazards regression. Clopidogrel was prescribed to a similar proportion of CYP2C19 normal (84.5%), rapid (82.9%), and ultrarapid metabolizers (80.6%) (P = 0.360). Clopidogrel-treated normal metabolizers (20.4 events/100 patient-years; adjusted hazard ratio (HR) 1.00, 95% confidence interval (CI), 0.75-1.33, P = 0.993) and clopidogrel-treated rapid or ultrarapid metabolizers (19.1 events/100 patient-years; adjusted HR 0.95, 95% CI, 0.69-1.30, P = 0.734) exhibited no difference in major atherothrombotic events compared with patients treated with prasugrel or ticagrelor (17.6 events/100 patient-years). In contrast, clopidogrel-treated intermediate and poor metabolizers exhibited significantly higher atherothrombotic event risk compared with prasugrel/ticagrelor-treated patients (adjusted HR 1.56, 95% CI, 1.12-2.16, P = 0.008). When comparing clopidogrel-treated rapid or ultrarapid metabolizers to normal metabolizers, no difference in atherothrombotic (adjusted HR 0.97, 95% CI, 0.73-1.29, P = 0.808) or bleeding events (adjusted HR 1.34, 95% CI, 0.83-2.17, P = 0.224) were observed. In a real-world setting of genotype-guided antiplatelet therapy, the CYP2C19*17 allele did not significantly impact post-PCI prescribing decisions or clinical outcomes. These results suggest the CYP2C19 *1/*17 and *17/*17 genotypes have limited clinical utility to guide antiplatelet therapy after PCI.
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Affiliation(s)
- Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip E Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nita A Limdi
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yiqing Chen
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James C Coons
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chrisly Dillon
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James M Stevenson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen E Weck
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
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32
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Gower MN, Ratner LR, Williams AK, Rossi JS, Stouffer GA, Lee CR. Clinical Utility of CYP2C19 Genotype-Guided Antiplatelet Therapy in Patients at Risk of Adverse Cardiovascular and Cerebrovascular Events: A Review of Emerging Evidence. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:239-252. [PMID: 32821149 PMCID: PMC7419635 DOI: 10.2147/pgpm.s231475] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
In patients undergoing percutaneous coronary intervention (PCI), the standard of care is dual antiplatelet therapy with a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin. Current clinical practice guidelines now recommend more potent P2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel in acute coronary syndrome (ACS). However, clopidogrel remains the most commonly prescribed P2Y12 inhibitor in the setting of PCI and is also the preferred agent in the treatment and secondary prevention of stroke. Clopidogrel is a prodrug that requires bioactivation by the CYP2C19 enzyme. It has been shown that clopidogrel use in patients who are CYP2C19 no function allele carriers are associated with impaired antiplatelet inhibition and a higher risk of major adverse cardiovascular and cerebrovascular events. Compared to clopidogrel, prasugrel and ticagrelor clinical response is not impacted by CYP2C19 genotype. Even with a demonstrated increased risk of adverse outcomes in CYP2C19 no function allele carriers treated with clopidogrel, routine implementation of CYP2C19 genotyping to guide antiplatelet therapy selection has remained controversial and has not been widely adopted. Recent results from multiple prospective randomized and nonrandomized clinical trials investigating the use of CYP2C19 genotype-guided antiplatelet therapy following PCI have advanced the evidence base demonstrating the clinical utility of this strategy. Multiple recent studies have examined the effects of CYP2C19 genotype on clopidogrel outcomes in the setting of stroke and neurointerventional procedures. In this review, we discern the clinical utility of using CYP2C19 genotype testing to guide antiplatelet therapy prescribing by evaluating the impact of CYP2C19 genotype-guided selection of antiplatelet therapy on clinical outcomes, summarizing emerging data from cardiovascular and neurology clinical studies, and discussing implications for clinical practice guidelines, remaining knowledge gaps and future research directions.
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Affiliation(s)
- Megan N Gower
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lindsay R Ratner
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Joseph S Rossi
- Division of Cardiology, UNC School of Medicine, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology, UNC School of Medicine, Chapel Hill, NC, USA.,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA.,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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33
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Lyu SQ, Yang YM, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Ren JM. The efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy compared with conventional antiplatelet therapy in patients with acute coronary syndrome or undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Platelets 2020; 31:971-980. [PMID: 32546030 DOI: 10.1080/09537104.2020.1780205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cytochrome P450 (CYP) 2C19 genotype is closely associated with the metabolism and efficacy of clopidogrel, thereby having an important impact on clinical outcomes of patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). This study aimed to evaluate the efficacy and safety of CYP2C19 genotype-guided antiplatelet therapy in patients with ACS or undergoing PCI. PubMed, EMBASE, the Cochrane Library and clinicaltrials.gov were searched to identify randomized controlled trials (RCTs) comparing CYP2C19 genotype-guided antiplatelet therapy with conventional therapy in patients with ACS or undergoing PCI. Eight RCTs involving 6708 patients were included in this meta-analysis. CYP2C19 genotype-guided antiplatelet therapy was slightly superior to the conventional antiplatelet therapy in reducing the risk of MACE [RR(95%CI): 0.71(0.51-0.98), p = .04]. Meanwhile, the genotype-guided therapy group had significantly lower incidence of myocardial infarction [RR(95%CI): 0.56(0.40-0.78), p < .01], but similar risk of all-cause mortality, cardiovascular mortality, stent thrombosis, urgent revascularization and stroke compared to the conventional therapy group. Incidences of major/minor bleeding and major bleeding were comparable between the two groups. In patients with ACS or undergoing PCI, CYP2C19 genotype-guided antiplatelet therapy displayed benefit over conventional antiplatelet therapy in reducing the risk of MACE and myocardial infarction, without increasing bleeding risk. Further RCTs are needed to provide more evidences for CYP2C19 genotype-guided antiplatelet therapy.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
| | - Jia-Meng Ren
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, People's Republic of China
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34
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Gurbel PA, Rout A, Tantry US. Pharmacogenetic considerations in antiplatelet therapy. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020. [DOI: 10.1080/23808993.2020.1768844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Paul A. Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, MD, USA
| | - Amit Rout
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, MD, USA
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Lifebridge Health, Baltimore, MD, USA
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