Is there a rationale for antiplatelet therapy in acute heart failure?

Epidemiology of heart failure hospitalization in patients with stable atherothrombotic disease: Insights from the TRA 2°P-TIMI 50 trial

BACKGROUND

Heart failure (HF) is a growing public health problem and ischemic heart disease is an important risk factor. Understanding the epidemiology of HF in patients with atherosclerosis may help identify subgroups at greater risk who have the potential to derive greater benefit from preventive strategies.

METHODS AND RESULTS

The TRA 2°P-TIMI 50 trial randomized 26,449 patients with stable atherosclerosis to the antiplatelet agent vorapaxar versus placebo. Hospitalization for HF (HHF) endpoints were adjudicated from serious adverse events by blinded structured review using established definitions. HHF incidence was estimated using Kaplan-Meier analysis. Independent predictors of HHF risk were identified using multivariable logistic regression. The effect of vorapaxar on HHF risk was explored using Cox regression. The estimated incidence of HHF at 3 years was 1.6%. Independent predictors of HHF included prior HF (adjusted odds ratio [adj-OR]: 8.31; 95% confidence interval [CI]: 6.56-10.54), age (adj-OR [per 10 years]: 1.67; 95% CI: 1.47-1.89), type 2 diabetes mellitus (T2DM; adj-OR: 2.55; 95% CI: 2.01-3.24), polyvascular disease (two-territory disease, adj-OR: 1.89; 95% CI: 1.46-2.44; three-territory disease, adj-OR: 2.68; 95% CI: 1.94-3.70), chronic kidney disease (CKD; adj-OR: 1.65; 95% CI: 1.30-2.11), body mass index (BMI; adj-OR [per 5 kg/m² ]: 1.15; 95% CI: 1.03-1.27), prior myocardial infarction (MI) (adj-OR: 1.35; 95% CI: 1.03-1.78), and hypertension (adj-OR: 1.44; 95% CI: 1.02-2.04). Patients who experienced HHF during follow-up had higher rates of subsequent rehospitalization and death. Vorapaxar did not modify the risk of HHF.

CONCLUSIONS

In patients with stable atherosclerosis, prior HF, age, T2DM, polyvascular disease, CKD, BMI, prior MI, and hypertension are important predictors of HHF risk.

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy

BACKGROUND

Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management.

METHODS

We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission.

RESULTS

A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) (p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62, p = 0.04).

CONCLUSION

Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.

Association of fractalkine with functional severity of heart failure and impact on clopidogrel efficacy in patients with ischemic heart disease

INTRODUCTION

Patients with heart failure (HF) display elevated levels of soluble fractalkine, a chemokine involved in inflammation processes, atherosclerosis and platelet activation. Further, fractalkine has been associated with reduced pharmacodynamic (PD) responsiveness to clopidogrel. The aim of this study was to investigate the association of fractalkine with the severity of HF and its impact on platelet activation and clopidogrel response in patients with coronary artery disease (CAD) with and without HF.

MATERIALS AND METHODS

This prospective PD study included 116 stable CAD patients on DAPT with aspirin and clopidogrel. Subjects were classified in two groups: patients with HF and reduced (<40%) left ventricular ejection fraction (HFrEF group, n = 56) and patients without HF (no HF group, n = 60). Clinical severity of HF was graded according to NYHA classification. Platelet function assays included vasodilator-stimulated phosphoprotein assay, multiple electrode aggregometry and light transmittance aggregometry. Fractalkine and P-selectin concentrations were determined by ELISA.

RESULTS

Fractalkine levels progressively increased with the severity of the disease in the HFrEF group (NYHA I: 471.2 ± 52.4 pg/ml, NYHA II: 500.5 ± 38.4 pg/ml, NYHA III: 638.9 ± 54.3 pg/ml, p for linear trend 0.023). Numerically higher concentrations of fractalkine were observed in the HFrEF group compared to the no HF group with borderline significance (p = 0.052). No significant differences in clopidogrel-induced platelet inhibition according to fractalkine values were observed in any of the groups.

CONCLUSIONS

Fractalkine levels were increased in patients with HFrEF and positively associated with the functional severity of the disease. No evident impact of fractalkine on clopidogrel PD efficacy was found.

Discordance Between VASP Phosphorylation and Platelet Aggregation in Defining High On-Clopidogrel Platelet Reactivity After ST-Segment Elevation Myocardial Infarction

To investigate potential clinical characteristics associated with discordance between platelet vasodilator-stimulated phosphoprotein phosphorylation (VASP-P) flow cytometry (FCM) assay and light transmission aggregometry (LTA) in defining high on-clopidogrel platelet reactivity (HPR) after ST-segment elevation myocardial infarction (STEMI). In this study, platelet responsiveness was measured by the above 2 methods simultaneously on day 1 and on day 6 of STEMI onset in 90 consecutive patients who underwent primary percutaneous coronary intervention. The FCM-derived platelet reactivity index and LTA-derived platelet aggregation rate were both significantly reduced after dual antiplatelet therapy on day 6. Multiple variable-adjusted logistic regression analysis revealed that smoking (odds ratio [OR]: 4.507, 95% confidence interval [CI]: 1.123-18.09, P = .034) and onset-to-admission time (per 1 hour increase, OR: 1.196, 95% CI: 1.023-1.398, P = .025) both were independent predictors for the discordance between the 2 methods. Additionally, improved correlation and concordance was observed in nonsmokers compared with smokers. Our data show that smoking and prolonged onset-to-admission time are associated with discordance between platelet VASP-P and LTA in defining HPR after STEMI, which should be considered when planning personalized antiplatelet therapy.

Correlation between mean platelet volume and B-type natriuretic peptide concentration in emergency patients with heart failure

BACKGROUND

In heart failure patients, mean platelet volume (MPV) may reflect increased platelet activation or increased numbers of large, hyper-aggregable platelets. B-type natriuretic peptide (BNP) concentration in blood is a sensitive and specific marker of heart failure, correlating with the severity and prognosis of illness, in patients presenting with acute dyspnea to the emergency department. This study evaluated the correlation between BNP concentration and MPV.

MATERIAL AND METHODS

Data were collected from 319 patients admitted to the emergency department of a cardiology hospital from January-July 2014. EDTA blood samples drawn at admission were analyzed using automated hematology system, and BNP concentration was measured using a fluorescence immunoassay.

RESULTS

The study included 190 patients with and 129 without acute heart failure (AHF). These groups had BNP concentration of 200-5000 ng/L and 5-98 ng/L, respectively. MPV levels were significantly higher in the AHF group (P<0.001). BNP concentrations were positively correlated with MPV (r=0.41, P<0.001) and neutrophil/lymphocyte ratio (r=0.38, P<0.001).

CONCLUSION

Increased MPV values correlate with BNP concentration, an indicator of HF severity and clinical status, in patients with AHF admitted to the emergency department.