1
|
Regan IE, Kelleher ST, Cox D, McMahon CJ. Efficacy and speed of effect after the first dose of aspirin in children with congenital heart disease. Cardiol Young 2024:1-9. [PMID: 39323360 DOI: 10.1017/s1047951124000581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
BACKGROUND Many paediatric studies report that patients must be established on aspirin therapy for a minimum of 5 days to achieve adequate response. This is not always practical especially in critical settings. Prospective identification of patients that are unresponsive to aspirin sooner could potentially prevent thrombotic events. AIMS The aim of this study was to investigate prospectively if the first dose of aspirin is effective in decreasing platelet aggregation, and thromboxane formation and if this can be measured after 2 hours in paediatric cardiology patients. A secondary aim was to identify a cut-off for a novel marker of aspirin responsiveness the maximum amplitude with arachidonic acid, which could potentially dramatically reduce the blood volume required. Third, we aimed to prospectively identify potentially non-responsive patients by spiking a sample of their blood ex vivo with aspirin. RESULTS The majority (92.3%) of patients were responsive, when measured 2 hours post first dose of aspirin. Non-response or inadequate response (7.7%) can also be identified at 2 hours after taking the first dose of aspirin. Additionally, we have shown a novel way to reduce blood sample volume requirements by measurement of the maximum amplitude with arachidonic acid as a marker of response, particularly for monitoring. CONCLUSIONS These findings of rapid efficacy in the majority of patients offer assurance in a sound, practical way to attending clinicians, patients, and families.
Collapse
Affiliation(s)
- Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
| | - Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Colin J McMahon
- School of Medicine, University College Dublin, Belfield, Dublin, Ireland
- National Children's Research Centre, Dublin, Ireland
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands
| |
Collapse
|
2
|
Mutschlechner D, Tscharre M, Wittmann F, Kitzmantl D, Schlöglhofer T, Wadowski PP, Laufer G, Eichelberger B, Lee S, Wiedemann D, Panzer S, Zimpfer D, Gremmel T. Platelet reactivity is associated with pump thrombosis in patients with left ventricular assist devices. Res Pract Thromb Haemost 2024; 8:102564. [PMID: 39391561 PMCID: PMC11466564 DOI: 10.1016/j.rpth.2024.102564] [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: 03/19/2024] [Revised: 07/28/2024] [Accepted: 08/30/2024] [Indexed: 10/12/2024] Open
Abstract
Background Patients with left ventricular assist devices (LVADs) are treated with a potent antithrombotic regimen to prevent pump thrombosis and thromboembolism. High on-treatment residual platelet reactivity (HRPR) is associated with ischemic outcomes in cardiovascular disease. Objectives In the current study, we investigated the prevalence and clinical impact of HRPR in stable LVAD patients. Methods Pump thrombosis, bleeding events, and death were assessed in 62 LVAD patients (19 HeartWare HVAD [Medtronic] and 43 HeartMate 3 [Abbott]) during a 2-year follow-up. Platelet aggregation was measured by multiple electrode aggregometry, and HRPR was defined as arachidonic acid (AA)-inducible platelet aggregation of ≥21 aggregation units. Soluble P-selectin was determined by enzyme-linked immunosorbent assay. Results Three patients (4.8%) had pump thrombosis and 10 patients (16.1%) suffered a bleeding complication. AA-inducible platelet aggregation was significantly higher in patients with pump thrombosis (P = .01), whereas platelet aggregation in response to adenosine diphosphate (ADP) and thrombin receptor-activating peptide (TRAP) was comparable between patients without and those with pump thrombosis (both P > .05). Platelet aggregation in response to AA, ADP, and TRAP was similar in patients without and with a bleeding event (all P > .05). HRPR was detected in 29 patients (46.8%) and was associated with significantly higher platelet aggregation in response to AA, ADP, and TRAP as well as higher levels of soluble P-selectin compared with patients without HRPR (all P < .05). All pump thromboses occurred in patients with HRPR (3 vs 0; P = .06) and HVAD. Conclusion Platelet reactivity is associated with pump thrombosis in LVAD patients. HRPR may represent a risk marker for pump thrombosis, particularly in HVAD patients.
Collapse
Affiliation(s)
- David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Pölten, Austria
| | - Franziska Wittmann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Kitzmantl
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Günther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University Graz, Graz, Austria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Silvia Lee
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
3
|
Thet MS, Khosravi A, Egbulonu S, Oo AY. Antiplatelet Resistance in Coronary Artery Bypass Grafting: A Systematic Review. Surg Res Pract 2024; 2024:1807241. [PMID: 38910604 PMCID: PMC11193597 DOI: 10.1155/2024/1807241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/26/2024] [Accepted: 06/08/2024] [Indexed: 06/25/2024] Open
Abstract
Background This systematic review examines the occurrence and implications of resistance to primary antiplatelet agents, aspirin and clopidogrel, often utilised in patients undergoing coronary artery bypass grafting (CABG), alongside the methodologies for assessment of such resistance. Methods An extensive literature search across various databases such as PubMed, MEDLINE via Ovid, Embase, and Cochrane CENTRAL until May 2024 was conducted to identify studies evaluating antiplatelet resistance in on-pump and off-pump CABG patients. Following quality assessment, only high-quality studies were incorporated into this review. Results This review included 19 studies with 3,915 patients, four of which were randomised controlled trials and 15 were observational studies. Aspirin resistance incidence ranged from 11.0% to 51.5%, while clopidogrel resistance was 22%. Antiplatelet resistance, assessed through a wide variety of methods, was associated with a 13 times increase in the risk of vein graft occlusion and increased rates of mortality, myocardial infarction, and target vessel revascularisation in the case of clopidogrel resistance. The effect of cardiopulmonary bypass on antiplatelet resistance remains ambiguous. Conclusion The academic literature lacks a standardised definition for antiplatelet resistance. Assessment methodologies greatly vary, leading to noninterchangeable outcomes. While aspirin resistance has a conflicting overall significant impact on adverse outcomes, clopidogrel resistance correlates with poorer clinical outcomes.
Collapse
Affiliation(s)
- Myat Soe Thet
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Amir Khosravi
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Samson Egbulonu
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| | - Aung Ye Oo
- Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
| |
Collapse
|
4
|
Gurbel PA, Bliden KP, Kundan P, Kraft D, Parekh R, Singh S, Babu AD, Shah AP, Chaudhary R, Tantry US. Early assessment of the pharmacokinetic and pharmacodynamic effects following acetylsalicylic acid loading: toward a definition for acute therapeutic response. J Thromb Thrombolysis 2024; 57:21-28. [PMID: 38066385 PMCID: PMC10830588 DOI: 10.1007/s11239-023-02914-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 02/01/2024]
Abstract
Despite decades of investigations, the optimal assessment of the "therapeutic response" to early after loading dose of acetylsalicylic acid (ASA) remains unclear. Limited information is available on the relation between pharmacodynamic (PD) and pharmacokinetic (PK) measurements assessed immediately after ASA administration. Serial PD and PK analyses were performed immediately after a single 162 or 650 mg dose of chewed and swallowed ASA in ten healthy adults. ASA response was defined as > 95% inhibition of serum thromboxane (Tx)B2, < 550 aspirin reaction units (ARU) by VerifyNow Aspirin (VN) test, and ≤ 20% arachidonic acid (AA)-induced platelet aggregation (PA). Correlation analyses between PK and PD measurements and receiver operating characteristic (ROC) curve analyses were performed. ASA response measured by VN test and AA-induced PA was achieved within 30 min of ASA administration. A correlation was observed between ARU and AA-induced maximum PA (r = 0.69, p < 0.001), serum TxB2 (r = 0.74 and p < 0.001), and serum TxB2 inhibition (r = 0.79, p < 0.001). In ROC curve analyses, ≤ 558 ARU and ≤ 7% AA-induced PA were associated with > 95% inhibition of TxB2. 686 ng/ml plasma ASA cut-off point was associated with > 95% inhibition of serum TxB2, ≤ 7% 1 mM AA-induced PA, and ≤ 585 ARU. A modest ~ 50% inhibition of TxB2 inhibition was associated with marked inhibition of 1 mM AA-induced platelet aggregation by LTA. Our analyses demonstrated important relationships between pharmacodynamic, and pharmacokinetic parameters measured immediately following oral ASA and cutoff values for ARU and AA-induced PA that is associated with > 95% inhibition of serum TxB2.
Collapse
Affiliation(s)
- Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA.
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Parshotam Kundan
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Danielle Kraft
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Rueshil Parekh
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Sahib Singh
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Aravind D Babu
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Anika P Shah
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| | - Rahul Chaudhary
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Artificial Intelligence for Holistic Evaluation and Advancement of Cardiovascular Thrombosis, Pittsburgh, PA, USA
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, 21209, USA
| |
Collapse
|
5
|
Rocca B, Patrono C. Precision antiplatelet therapy. Res Pract Thromb Haemost 2023; 7:100138. [PMID: 37215094 PMCID: PMC10193296 DOI: 10.1016/j.rpth.2023.100138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/23/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
A State of the Art lecture titled "Personalizing Antiplatelet Therapy Based on Platelet Turnover and Metabolic Phenotype" was presented by Bianca Rocca at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2022. Increased variability in drug response may be associated with serious, mechanism-based and off-target side effects, especially in the case of drugs that do not routinely undergo therapeutic drug monitoring, such as antiplatelet drugs or direct oral anticoagulants. Precision pharmacology can be defined as the identification of a drug regimen that maximizes the benefit/risk balance at the level of an individual patient. Key tools for identifying relevant sources of variability and developing precision drug dosing are represented by genetic, biochemical, and pharmacological biomarkers recognized as a valid surrogate or strong predictor of major clinical complications. Pharmacodynamic, pharmacokinetic, and/or disease-related biomarkers are central to identifying the right population to be targeted, characterizing the sources of variability in drug response, guiding precision treatments that maximize benefits and minimize risks, and designing precision dosing trials. Another valuable tool for guiding precision pharmacology is represented by in silico pharmacokinetic/pharmacodynamic models and simulations instructed by real-world data of validated biomarkers. This review critically analyzes the tools for precision dosing and exemplifies conditions in which precision dosing can considerably optimize the efficacy and safety of antiplatelet drugs, namely aspirin and P2Y12 receptor blockers, used alone and in combination. Finally, we summarize relevant new data on this topic presented during the 2022 ISTH Congress.
Collapse
Affiliation(s)
- Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine and Fondazione Policlinico Universitario Agostino Gemelli and Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| | - Carlo Patrono
- Section of Pharmacology, Catholic University School of Medicine and Fondazione Policlinico Universitario Agostino Gemelli and Istituto di Ricerca e Cura a Carattere Scientifico, Rome, Italy
| |
Collapse
|
6
|
Wang T, Chen X, Li H, Chen W, Xu Y, Yao Y, Zhang H, Han Y, Zhang L, Que C, Gong J, Qiu X, Zhu T. Pro-thrombotic changes associated with exposure to ambient ultrafine particles in patients with chronic obstructive pulmonary disease: roles of lipid peroxidation and systemic inflammation. Part Fibre Toxicol 2022; 19:65. [PMID: 36280873 PMCID: PMC9590143 DOI: 10.1186/s12989-022-00503-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exposure to particulate matter air pollution is associated with an increased risk of cardiovascular mortality in patients with chronic obstructive pulmonary disease (COPD), but the underlying mechanisms are not yet understood. Enhanced platelet and pro-thrombotic activity in COPD patients may explain their increased cardiovascular risk. We aim to explore whether short-term exposure to ambient particulate matter is associated with pro-thrombotic changes in adults with and without COPD, and investigate the underlying biological mechanisms in a longitudinal panel study. Serum concentration of thromboxane (Tx)B2 was measured to reflect platelet and pro-thrombotic activity. Lipoxygenase-mediated lipid peroxidation products (hydroxyeicosatetraenoic acids [HETEs]) and inflammatory biomarkers (interleukins [ILs], monocyte chemoattractant protein-1 [MCP-1], tumour necrosis factor alpha [TNF-α], and macrophage inflammatory proteins [MIPs]) were measured as potential mediating determinants of particle-associated pro-thrombotic changes. RESULTS 53 COPD and 82 non-COPD individuals were followed-up on a maximum of four visits conducted from August 2016 to September 2017 in Beijing, China. Compared to non-COPD individuals, the association between exposure to ambient ultrafine particles (UFPs) during the 3-8 days preceding clinical visits and the TxB2 serum concentration was significantly stronger in COPD patients. For example, a 103/cm3 increase in the 6-day average UFP level was associated with a 25.4% increase in the TxB2 level in the COPD group but only an 11.2% increase in the non-COPD group. The association in the COPD group remained robust after adjustment for the levels of fine particulate matter and gaseous pollutants. Compared to the non-COPD group, the COPD group also showed greater increases in the serum concentrations of 12-HETE (16.6% vs. 6.5%) and 15-HETE (9.3% vs. 4.5%) per 103/cm3 increase in the 6-day UFP average. The two lipid peroxidation products mediated 35% and 33% of the UFP-associated increase in the TxB2 level of COPD patients. UFP exposure was also associated with the increased levels of IL-8, MCP-1, MIP-1α, MIP-1β, TNF-α, and IL-1β in COPD patients, but these inflammatory biomarkers did not mediate the TxB2 increase. CONCLUSIONS Short-term exposure to ambient UFPs was associated with a greater pro-thrombotic change among patients with COPD, at least partially driven by lipoxygenase-mediated pathways following exposure. Trial registration ChiCTR1900023692 . Date of registration June 7, 2019, i.e. retrospectively registered.
Collapse
Affiliation(s)
- Teng Wang
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Xi Chen
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China.,Hebei Technology Innovation Center of Human Settlement in Green Building (TCHS), Shenzhen Institute of Building Research Co., Ltd., Xiongan, China
| | - Haonan Li
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Wu Chen
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Yifan Xu
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Yuan Yao
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Hanxiyue Zhang
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Yiqun Han
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China.,Environmental Research Group, MRC Centre for Environment and Health, Imperial College London, London, UK
| | - Lina Zhang
- Shi Cha Hai Community Health Service Center, Beijing, China
| | - Chengli Que
- Peking University First Hospital, Peking University, Beijing, China
| | - Jicheng Gong
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Xinghua Qiu
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China
| | - Tong Zhu
- BIC-ESAT and SKL-ESPC, College of Environmental Sciences and Engineering, Peking University, Beijing, China.
| |
Collapse
|
7
|
Hegde NN, Mathew N, Thachathodiyl R, Menon JC. Personalized allocation of acetylsalicylic acid therapy for secondary prevention of coronary artery disease. Front Cardiovasc Med 2022; 9:1004473. [PMID: 36237906 PMCID: PMC9551163 DOI: 10.3389/fcvm.2022.1004473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background A single-daily dose of 75 mg of acetylsalicylic acid inhibits 100% of thromboxane-B2 synthesis within 30–60 min. Thromboxane-B2 synthesis then recovers slowly as new platelets are released from the bone marrow. Normally, only 10% of the platelets are replaced daily by new platelets entering circulation. Hence, 24 h after a dose of acetylsalicylic acid, thromboxane-B2 synthesis is still suppressed by more than 90%. Hence, there is an adequate anti-platelet effect even after 24 h of acetylsalicylic acid intake. However, some patients treated with once-daily acetylsalicylic acid may have an incomplete 24-h suppression of thromboxane-B2 synthesis due to increased platelet turnover. The response could be improved in such patients by twice-daily acetylsalicylic acid administration. This study aimed to identify such a group of patients who would benefit from a twice-daily dose of acetylsalicylic acid. Materials and methods Serum thromboxane-B2 levels were measured in 79 patients with coronary artery disease receiving 75 mg of acetylsalicylic acid for secondary prophylaxis. Serum levels of thromboxane-B2 were measured after 4 and 24 h of acetylsalicylic acid intake. Patients were then classified into three groups: steady suppression group (serum thromboxane B2 is adequately suppressed at 4 and 24 h), i.e., adequate response to acetylsalicylic acid; fast recovery group (more than 10% rise in serum thromboxane-B2 levels at 24-h when compared to at 4-h) and non-responders (serum thromboxane-B2 levels of >3,100 pg/ml after 4 h of acetylsalicylic acid intake). Patients in the fast recovery group were given twice-daily acetylsalicylic acid and thromboxane-B2 levels were re-measured. Results A total of 20 patients (24.3%) had steady suppression of thromboxane-B2 and 11 patients (13.9%) belonged to the fast recovery group, i.e., thromboxane-B2 levels were adequately suppressed at 4 h but had recovered by more than 10% at 24 h; which was adequately suppressed by twice-daily acetylsalicylic acid (p 0.004). A total of 48 patients (60.8%) were non-responders. Conclusion Twice-daily acetylsalicylic acid may be beneficial if serum thromboxane-B2 levels at 4 h are <3,100 and >3,100 pg/ml at 24 h. If thromboxane-B2 levels at 4 and 24 h is <3100 pg/ml but if there is a >10% rise in serum thromboxane B2 at 24 h as compared to that at 4 h, then twice-daily acetylsalicylic acid should be considered. However, if thromboxane-B2 at 4 and 24 h is >3,100 pg/ml consider switching over to a P2Y12 inhibitor.
Collapse
|
8
|
Elshafei MN, Imam Y, Alsaud AE, Chandra P, Parray A, Abdelmoneim MS, Obeidat K, Saeid R, Ali M, Ayadathil R, Mohamed MFH, Abdallah IM, Mohammed S, Akhtar N, Danjuma MIM. The impact of enteric coating of aspirin on aspirin responsiveness in patients with suspected or newly diagnosed ischemic stroke: prospective cohort study: results from the (ECASIS) study. Eur J Clin Pharmacol 2022; 78:1801-1811. [PMID: 36121499 PMCID: PMC9546947 DOI: 10.1007/s00228-022-03391-2] [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: 12/13/2021] [Accepted: 08/22/2022] [Indexed: 11/25/2022]
Abstract
Background and purpose Uncertainty remains regarding the impact of enteric-coated aspirin (EC-ASA) on secondary prevention of ischemic stroke compared to plain aspirin (P-ASA). Hence, this study was designed to investigate the effect of EC formulation on ASA response via evaluating thromboxane B2 (TXB2) levels in patients with suspected or newly diagnosed stroke. Methods A prospective cohort study on suspected or newly diagnosed ischemic stroke patients who are aspirin-naive was conducted. Patients were received either EC aspirin or plain aspirin for at least 3 days. The primary outcome was the proportion of aspirin non-responsiveness between two groups (level of residual serum TXB2 associated with elevated thrombotic risk (< 99.0% inhibition or TXB2 > 3.1 ng/ml) within 72 h after three daily aspirin doses, while secondary outcomes were the incidence of early gastrointestinal tract (GIT) bleeding with the various aspirin preparations. (Trial registration: Clinicaltrials.gov NCT04330872 registered on 02 April 2020). Results Of 42 patients, ischemic strokes were confirmed in both P-ASA (81%) and EC-ASA (67%) arms. ASA non-responsiveness showed no significant difference between the two formulations (P-ASA vs. EC-ASA; 28.6% vs 23.8%; P = 0.726). Univariate and multivariate logistic regression analysis showed that patients treated with EC-ASA were more likely to have a lower rate of non-responders compared to P-ASA (unadjusted OR 0.78; 95% CI 0.20, 3.11); with the risk highest in type 2 diabetic patients with HBA1c > 6.5% (adjusted OR 6; 95% CI 1.02, 35.27; P = 0.047). No incidence of GIT bleeding observed throughout the study. Conclusion A significant proportion of ASA non-responsiveness was recorded regardless of ASA formulation administered. The increased risk of ASA non-responsiveness in diabetic patients needs further exploration by larger prospective studies.
Collapse
Affiliation(s)
- Mohamed Nabil Elshafei
- Clinical Pharmacy Department, Hamad General Hospital, Hamad Medical Corporation, P.O. 3050, Doha, Qatar.
| | - Yahia Imam
- Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Arwa Ebrahim Alsaud
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Prem Chandra
- Biostatstics Section, Medical Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Aijaz Parray
- The Neuroscience Institute, Academic Health Systems, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed S Abdelmoneim
- Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,The Neuroscience Institute, Academic Health Systems, Hamad Medical Corporation, Doha, Qatar
| | - Khaldun Obeidat
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Razan Saeid
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Ali
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Raheem Ayadathil
- The Neuroscience Institute, Academic Health Systems, Hamad Medical Corporation, Doha, Qatar
| | - Mouhand F H Mohamed
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ibtihal M Abdallah
- Clinical Pharmacy Department, Hamad General Hospital, Hamad Medical Corporation, P.O. 3050, Doha, Qatar
| | - Shaban Mohammed
- Department of Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Mohammed Ibn-Masoud Danjuma
- Internal Medicine Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Qatar University, Doha, Qatar
| |
Collapse
|
9
|
Li XL, Wang Q, Jia GD, Yin HJ, Wang YH, Hu C, Wang XQ, Yang Y. Apolipoprotein E*Ɛ2 carriers exhibit high aspirin-treated platelet reactivity and low cardiovascular risk during long-term aspirin treatment. Age Ageing 2022; 51:6596556. [PMID: 35647761 DOI: 10.1093/ageing/afac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/30/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Apolipoprotein E (APOE) loci, including rs429358 (Ɛ4) and rs7412 (Ɛ2), are involved in cardiovascular (CV) health. However, their effect on the CV-protective effect of aspirin remains unknown. METHODS A total of 515 aspirin-treated individuals with existing CV diseases were recruited, and their APOE genotypes, platelet functions and other routine laboratory parameters were assessed when they enrolled. The first major CV events (myocardial infarction, stroke, revascularisation and CV death) and all CV events (major CV events plus unstable angina and transient ischaemic attack) during a mean 5.2-year follow-up period were recorded. RESULTS After adjusting for age, gender, BMI, lifestyle, lipid profiles and other CV drugs and comorbidities, Ɛ2 carriers were found to exhibit ~80% lower risk of major CV and 60% lower risk of all CV (HR = 0.186, CI: 0.048-0.715, P = 0.014; HR = 0.435, CI: 0.234-0.812, P = 0.009, respectively) than Ɛ2 noncarriers. Furthermore, high incidence of high platelet reactivity assessed by arachidonic acid-induced light transmission aggregometry (23.4 vs. 13.7%, P = 0.038), triglyceride and haemoglobin and low low-density lipoprotein were observed. Ɛ4 carriers had slightly increased cholesterol and hypercholesterolemia incidence relative to Ɛ4 noncarriers. CONCLUSIONS Our results demonstrated that APOE*Ɛ2 carriers can derive additional CV benefit from long-term aspirin treatment. Moreover, it was observed that APOE2 interacts with cyclooxygenase-1 (COX-1) and upregulates its activity. The CV-protective effect of aspirin in Ɛ2 carriers is likely attributed to APOE2 upregulating vascular COX-1-mediated CV protective pathway, together with aspirin partially inhibiting platelet COX-1-mediated platelet aggregation.
Collapse
Affiliation(s)
- Xiao-Li Li
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| | - Qiang Wang
- Department of Urology, Peking University People's Hospital , Beijing 100044, China
| | - Guo-Dong Jia
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| | - Hui-Jun Yin
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| | - Yao-Hui Wang
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| | - Chao Hu
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| | - Xiao-Qing Wang
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| | - Yang Yang
- Department of the Eighth Healthcare , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
- Chinese People’s Liberation Army General Hospital , Second Medical Center, National Clinical Research Center for Geriatric Diseases, , Beijing 1000853, China
| |
Collapse
|
10
|
Angiolillo DJ, Prats J, Deliargyris EN, Schneider DJ, Scheiman J, Kimmelstiel C, Steg PG, Alberts M, Rosengart T, Mehran R, Bhatt DL. Pharmacokinetic and Pharmacodynamic Profile of a Novel Phospholipid Aspirin Formulation. Clin Pharmacokinet 2022; 61:465-479. [PMID: 35060092 PMCID: PMC8773391 DOI: 10.1007/s40262-021-01090-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 12/25/2022]
Abstract
Aspirin is one of the most widely used medicines. Although aspirin is commonly utilized for the treatment of several medical conditions, its broadest uptake is for the prevention of recurrent ischemic events in patients with atherosclerotic disease. Its mechanism of action of inhibiting platelet activation via blockade of thromboxane A2 production is unique and is not covered by any other antiplatelet agents. While plain, uncoated, immediate-release aspirin is used in acute settings to help assure rapid absorption, enteric-coated aspirin formulations dominate current chronic use, particularly in North America, including for secondary prevention of cardiovascular events. The unmet needs with current aspirin formulations include a high risk of gastrointestinal (GI) adverse events with plain aspirin, which enteric-coated formulations are not able to overcome, and subject to erratic absorption leading to reduced drug bioavailability. These observations underscore the need for aspirin formulations with a more favorable safety and efficacy profile. Phospholipid-aspirin complex (PL-ASA) is a novel formulation designed to address these needs. It is associated with reduced local acute GI injury compared with plain aspirin, and predictable absorption resulting in more reliable platelet inhibition compared with enteric-coated tablets. This review explores the rationale and pharmacologic profile of PL-ASA intended to address the unmet needs for aspirin therapy.
Collapse
Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, 655 West 8th street, Jacksonville, FL, 32209, USA.
| | | | | | - David J Schneider
- Cardiovascular Division Department of Medicine and Cardiovascular Research Institute, University of Vermont Burlington, Burlington, VT, USA
| | - James Scheiman
- iDivision of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Carey Kimmelstiel
- Division of Cardiology, Tufts Medical Center Boston, Boston, MA, USA
| | - Ph Gabriel Steg
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, INSERM-U1148, Paris, France
| | - Mark Alberts
- Department of Neurology, Hartford Hospital, Hartford, CT, USA
| | - Todd Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
11
|
Myers RA, Ortel TL, Waldrop A, Dave S, Ginsburg GS, Voora D. Aspirin effects on platelet gene expression are associated with a paradoxical, increase in platelet function. Br J Clin Pharmacol 2021; 88:2074-2083. [PMID: 34705291 PMCID: PMC9007832 DOI: 10.1111/bcp.15127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 01/04/2023] Open
Abstract
Aspirin has known effects beyond inhibiting platelet cyclooxygenase-1 (COX-1) that have been incompletely characterized. Transcriptomics can comprehensively characterize the on- and off-target effects of medications. We used a systems pharmacogenomics approach of aspirin exposure in volunteers coupled with serial platelet function and purified platelet mRNA sequencing to test the hypothesis that aspirin's effects on the platelet transcriptome are associated with platelet function. We prospectively recruited 74 adult volunteers for a randomized crossover study of 81- vs. 325 mg/day, each for 4 weeks. Using mRNA sequencing of purified platelets collected before and after each 4-week exposure, we identified 208 aspirin-responsive genes with no evidence for dosage effects. In independent cohorts of healthy volunteers and patients with diabetes, we validated aspirin's effects on five genes: EIF2S3, CHRNB1, EPAS1, SLC9A3R2 and HLA-DRA. Functional characterization of the effects of aspirin on mRNA as well as platelet ribosomal RNA demonstrated that aspirin may act as an inhibitor of protein synthesis. Database searches for small molecules that mimicked the effects of aspirin on platelet gene expression in vitro identified aspirin but no other molecules that share aspirin's known mechanisms of action. The effects of aspirin on platelet mRNA were correlated with higher levels of platelet function both at baseline and after aspirin exposure-an effect that counteracts aspirin's known antiplatelet effect. In summary, this work collectively demonstrates a dose-independent effect of aspirin on the platelet transcriptome that counteracts the well-known antiplatelet effects of aspirin.
Collapse
Affiliation(s)
- Rachel A Myers
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Alexander Waldrop
- Center for Genomics and Computational Biology, Duke University, Durham, NC, United States
| | - Sandeep Dave
- Center for Genomics and Computational Biology, Duke University, Durham, NC, United States
| | - Geoffrey S Ginsburg
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Deepak Voora
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| |
Collapse
|
12
|
Once- versus Twice-Daily Aspirin in Patients at High Risk of Thrombotic Events: Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2021; 21:63-71. [PMID: 32394295 DOI: 10.1007/s40256-020-00409-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acetylsalicylic acid (ASA) is a frequently used antiplatelet agent, although some individuals have reduced antiplatelet responses on ASA, with recurrent ischemic events. It has been proposed that shortening the ASA dosing interval may overcome the time-dependent renewal of the drug target, leading to a greater antiplatelet effect. We conducted a systematic review of randomized controlled trials (RCTs) to determine the efficacy of once- versus twice-daily ASA in conditions with increased platelet turnover. METHODS We conducted a systematic review and meta-analysis by searching the CENTRAL, MEDLINE, and Embase databases for RCTs assessing once- versus twice-daily ASA. Data were screened, extracted, and appraised by two independent reviewers, and were pooled using a random-effects model. The primary outcomes were major adverse cardiovascular events (MACEs) and serum thromboxane B2 (TxB2). Other pharmacodynamic measures were retrieved as secondary outcomes. Results were reported as mean differences with corresponding 95% confidence intervals (CIs). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Seven RCTs were included, enrolling 379 participants overall. None of the studies reported clinical outcomes. Pooled results showed that compared with once-daily ASA, twice-daily ASA was associated with a decrease in mean TxB2 of 1.42 ng/mL (95% CI - 2.71 to - 0.13; I2 = 66%). We found no differences in subgroup analyses based on disease subtype, trial blinding, or trial design. A greater antiplatelet activity of the twice-daily regimen was also found when using PFA-100-ADP methods, although not when using the VerifyNow, LTA-AA, and multiplate methods. CONCLUSIONS Twice-daily ASA was associated with a greater antiplatelet effect compared with standard once-daily ASA.
Collapse
|
13
|
Capodanno D, Angiolillo DJ. Antithrombotic Therapy for Atherosclerotic Cardiovascular Disease Risk Mitigation in Patients With Coronary Artery Disease and Diabetes Mellitus. Circulation 2020; 142:2172-2188. [PMID: 33253005 DOI: 10.1161/circulationaha.120.045465] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with diabetes mellitus (DM) are characterized by enhanced thrombotic risk attributed to multiple mechanisms including hyperreactive platelets, hypercoagulable status, and endothelial dysfunction. As such, they are more prone to atherosclerotic cardiovascular events than patients without DM, both before and after coronary artery disease (CAD) is established. In patients with DM without established CAD, primary prevention with aspirin is not routinely advocated because of its increased risk of major bleeding that largely offsets its ischemic benefit. In patients with DM with established CAD, secondary prevention with antiplatelet drugs is an asset of pharmacological strategies aimed at reducing the risk of atherosclerotic cardiovascular events and their adverse prognostic consequences. Such antithrombotic strategies include single antiplatelet therapy (eg, with aspirin or a P2Y12 inhibitor), dual antiplatelet therapy (eg, aspirin combined with a P2Y12 inhibitor), and dual-pathway inhibition (eg, aspirin combined with the vascular dose of the direct oral anticoagulant rivaroxaban) for patients with chronic ischemic heart disease, acute coronary syndromes, and those undergoing percutaneous coronary intervention. Because of their increased risk of thrombotic complications, patients with DM commonly achieve enhanced absolute benefit from more potent antithrombotic approaches compared with those without DM, which most often occurs at the expense of increased bleeding. Nevertheless, studies have shown that when excluding individuals at high risk for bleeding, the net clinical benefit favors the use of intensified long-term antithrombotic therapy in patients with DM and CAD. Several studies are ongoing to establish the role of novel antithrombotic strategies and drug formulations in maximizing the net benefit of antithrombotic therapy for patients with DM. The scope of this review article is to provide an overview of current and evolving antithrombotic strategies for primary and secondary prevention of atherosclerotic cardiovascular events in patients with CAD and DM.
Collapse
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| |
Collapse
|
14
|
Residual platelet reactivity in low-dose aspirin-treated patients with class 1 obesity. Vascul Pharmacol 2020; 136:106819. [PMID: 33207279 DOI: 10.1016/j.vph.2020.106819] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/02/2020] [Accepted: 11/13/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent data suggest a decreased clinical efficacy of low-dose aspirin in patients weighing ≥70 kg. We therefore investigated the impact of body weight and class 1 obesity on thromboxane generation and platelet reactivity to arachidonic acid (AA) in 316 patients on dual antiplatelet therapy following angioplasty and stenting. METHODS Platelet surface expression of P-selectin and activated glycoprotein (GP) IIb/IIIa in response to AA were determined by flow cytometry as sensitive markers of platelet activation. Urinary 11-dehydro-thromboxane B2 (11-dehydro-TXB2) and serum TXB2 were measured by commercially-available immunoassays. On-treatment residual AA-inducible platelet aggregation was assessed by light transmission aggregometry (LTA), the VerifyNow aspirin assay and multiple electrode aggregometry (MEA). RESULTS Class 1 obesity was independently associated with increased platelet surface expression of P-selectin and activated GPIIb/IIIa, but not with urinary 11-dehydro-TXB2, serum TXB2, and on-treatment platelet aggregation by all assays. Of all measured parameters, only MEA showed a positive albeit very weak correlation with body weight (r = 0.13, p = 0.02). Furthermore, the results of all tests did not differ significantly between patients without and with a body weight ≥ 70 kg. After adjustment for age and diabetes by multivariate logistic regression analysis, the frequency of high-on treatment residual TXB2 generation and high on-treatment residual AA-inducible platelet reactivity (HRTG/HRPR) did not differ significantly between obese and non-obese patients. CONCLUSION Class 1 obesity is associated with enhanced platelet activation in response to AA in patients on dual antiplatelet therapy. This seems to be independent of cyclooxygenase-1 inhibition and does not translate into HRTG/HRPR.
Collapse
|
15
|
Angiolillo DJ, Bhatt DL, Lanza F, Cryer B, Dong JF, Jeske W, Zimmerman RR, von Chong E, Prats J, Deliargyris EN, Marathi U. Pharmacokinetic/pharmacodynamic assessment of a novel, pharmaceutical lipid-aspirin complex: results of a randomized, crossover, bioequivalence study. J Thromb Thrombolysis 2020; 48:554-562. [PMID: 31420787 PMCID: PMC6800884 DOI: 10.1007/s11239-019-01933-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aspirin (acetylsalicylic acid, ASA) can lead to gastrointestinal mucosal injury through disruption of its protective phospholipid bilayer. A liquid formulation of a novel pharmaceutical lipid-aspirin complex (PL-ASA) was designed to prevent this disruption. We sought to determine the pharmacokinetic (PK)/pharmacodynamic (PD) characteristics of PL-ASA compared with immediate release aspirin (IR-ASA). In this active-control crossover study, 32 healthy volunteers were randomized to receive 1 of 2 dose levels (a single dose of 325 mg or 650 mg) of either PL-ASA or IR-ASA. After a 2-week washout period between treatment assignments, subjects received a single dose of the alternative treatment, at the same dose level. The primary objectives of the study were to assess, for PL-ASA and IR-ASA at 325 mg and 650 mg dose levels, PK and PD bioequivalence, and safety, over a 24-h period after administration of both drugs. PK parameters were similar for PL-ASA and IR-ASA, and met FDA-criteria for bioequivalence. Regarding PD, both drugs also showed Cmin TxB2 values below 3.1 ng/mL (cut-off associated with decreased cardiovascular events) and > 99% inhibition of serum TxB2 ( ≥ 95% inhibition represents the cut-off for aspirin responders) along with similar results in several secondary PK/PD parameters. There were no serious adverse events or changes from baseline in vital signs or laboratory values in either of the 2 treatment groups. PL-ASA's novel liquid formulation has similar PK and PD performance compared with IR-ASA, supporting functional and clinical equivalence. These data coupled with the improved gastric safety of PL-ASA suggest that this novel formulation may exhibit an improved benefit-risk profile, warranting evaluation in future trials.Clinical trial registration: http://www.clinicaltrials.gov . Unique Identifier: NCT04008979.
Collapse
Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, 655 West 8th street, Jacksonville, FL, 32209, USA.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Frank Lanza
- Houston Institute for Clinical Research, Houston, TX, USA
| | - Byron Cryer
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Jin-Fei Dong
- Division of Hematology, Department of Medicine, University of Washington, Member, BloodWorks NW Research Institute, Seattle, WA, USA
| | - Walter Jeske
- Cardiovascular Research Institute, Loyola University Chicago Health Sciences Division, Maywood, IL, USA
| | | | | | | | | | | |
Collapse
|
16
|
Fontana P, Roffi M, Reny JL. Platelet Function Test Use for Patients with Coronary Artery Disease in the Early 2020s. J Clin Med 2020; 9:jcm9010194. [PMID: 31936845 PMCID: PMC7019825 DOI: 10.3390/jcm9010194] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
In the field of antithrombotics, precision medicine is of particular interest, as it may lower the incidence of potentially life-threatening side effects. Indeed, antiplatelet drugs such as P2Y12 inhibitors are one of the most common causes of emergency admissions for drug-related adverse events. The last ten years have seen a continuous debate on whether platelet function tests (PFTs) should be used to tailor antiplatelet drugs to cardiovascular patients. Large-scale randomized studies investigating the escalation of antiplatelet therapies according to the results of PFTs were mostly negative. Potent P2Y12 inhibitors are recommended as a first-line treatment in acute coronary syndrome patients, bringing the bleeding risk at the forefront. De-escalation from prasugrel or ticagrelor to clopidogrel is now considered, with or without the use of a PFT. This review covers recent advances in escalation and de-escalation strategies based on PFTs in various clinical settings. It also describes the main features of the most popular platelet function tests as well as the potential added value of genetic testing. Finally, we detail practical suggestions on how PFTs could be used in clinical practice.
Collapse
Affiliation(s)
- Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Division of Angiology and Haemostasis, Geneva University Hospitals, 1205 Geneva, Switzerland
- Correspondence: ; Tel.: +41-22-372-97-51; Fax: +41-22-372-98-91
| | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Division of General Internal Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
| |
Collapse
|
17
|
Patrono C, Rocca B. Measurement of Thromboxane Biosynthesis in Health and Disease. Front Pharmacol 2019; 10:1244. [PMID: 31736753 PMCID: PMC6832017 DOI: 10.3389/fphar.2019.01244] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/27/2019] [Indexed: 12/17/2022] Open
Abstract
Thromboxane (TX) A2 is a chemically unstable lipid mediator involved in several pathophysiologic processes, including primary hemostasis, atherothrombosis, inflammation, and cancer. In human platelets, TXA2 is the major arachidonic acid derivative via the cyclooxygenase (COX)-1 pathway. Assessment of platelet TXA2 biosynthesis can be performed ex vivo through measurement of serum TXB2, an index of platelet COX-1 activity, as well as in vivo through measurement of urinary enzymatic metabolites, a non-invasive index of platelet activation. This article reviews the main findings of four decades of clinical investigation based on these analytical approaches, focusing on the measurement of TXA2 metabolites to characterize the pathophysiologic role of transiently or persistently enhanced platelet activation and to describe the clinical pharmacology of COX-1 inhibition in health and disease.
Collapse
Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| |
Collapse
|
18
|
Chiang JY, Lee SH, Chen YC, Wu CK, Chuang JY, Lo SC, Yeh HM, Yeh SFS, Hsu CA, Lin BB, Chang PC, Chang CH, Liang HJ, Chiang FT, Lin CY, Juang JMJ. Metabolomic Analysis of Platelets of Patients With Aspirin Non-Response. Front Pharmacol 2019; 10:1107. [PMID: 31680941 PMCID: PMC6797853 DOI: 10.3389/fphar.2019.01107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 08/28/2019] [Indexed: 12/20/2022] Open
Abstract
Background: Aspirin is the most commonly used antiplatelet agent for the prevention of cardiovascular diseases. However, a certain proportion of patients do not respond to aspirin therapy. The mechanisms of aspirin non-response remain unknown. The unique metabolomes in platelets of patients with coronary artery disease (CAD) with aspirin non-response may be one of the causes of aspirin resistance. Materials and Methods: We enrolled 29 patients with CAD who were aspirin non-responders, defined as a study subject who were taking aspirin with a platelet aggregation time less than 193 s by PFA-100, and 31 age- and sex-matched patients with CAD who were responders. All subjects had been taking 100 mg of aspirin per day for more than 1 month. Hydrophilic metabolites from the platelet samples were extracted and analyzed by nuclear magnetic resonance (NMR). Both 1D 1H and 2D J-resolved NMR spectra were obtained followed by spectral processing and multivariate statistical analysis, such as partial least squares discriminant analysis (PLS-DA). Results: Eleven metabolites were identified. The PLS-DA model could not distinguish aspirin non-responders from responders. Those with low serum glycine level had significantly shorter platelet aggregation time (mean, 175.0 s) compared with those with high serum glycine level (259.5 s). However, this association became non-significant after correction for multiple tests. Conclusions: The hydrophilic metabolic profile of platelets was not different between aspirin non-responders and responders. An association between lower glycine levels and higher platelet activity in patients younger than 65 years suggests an important role of glycine in the pathophysiology of aspirin non-response.
Collapse
Affiliation(s)
- Jiun-Yang Chiang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sheng-Han Lee
- Institute of Environmental Health, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yen-Ching Chen
- College of Public Health, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Cho-Kai Wu
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jing-Yuan Chuang
- Department of Medical Laboratory Science and Biotechnology, China Medical University, Taichung, Taiwan
| | - Shyh-Chyi Lo
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huei-Ming Yeh
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shih-Fan Sherri Yeh
- Department of Environmental and Occupational Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Cheng-An Hsu
- Division of Haematology, Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Bin-Bin Lin
- Division of Haematology, Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Pi-Chu Chang
- Division of Haematology, Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsin Chang
- Division of Haematology, Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hao-Jan Liang
- Institute of Environmental Health, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Fu-Tien Chiang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.,Cardiovascular Center, Fu-Jen Catholic University Hospital, New Taipei, Taiwan
| | - Ching-Yu Lin
- Institute of Environmental Health, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
19
|
Ni R, Vaezzadeh N, Zhou J, Weitz JI, Cattaneo M, Gross PL. Effect of Different Doses of Acetylsalicylic Acid on the Antithrombotic Activity of Clopidogrel in a Mouse Arterial Thrombosis Model. Arterioscler Thromb Vasc Biol 2019; 38:2338-2344. [PMID: 30354213 DOI: 10.1161/atvbaha.118.311404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective- Dual-antiplatelet therapy with acetylsalicylic acid and a P2Y12 antagonist, such as clopidogrel, is the standard of care for acute coronary syndromes. However, the drugs have divergent effects on the formation of cAMP, an inhibitory second messenger. Thus, by inhibiting the synthesis of prostacyclin, acetylsalicylic acid reduces cAMP formation, whereas clopidogrel potentiates it. Therefore, with higher doses of acetylsalicylic acid, the potentiation of cAMP production by clopidogrel may be attenuated, which could limit the antithrombotic potential of the drug combination. The purpose of this study was to examine this possibility in vivo. Approach and Results- Mice were given oral acetylsalicylic acid at varying doses, oral clopidogrel (5 mg/kg body weight), or both. At doses of 0.15 and 0.6 mg/kg, acetylsalicylic acid inhibited arachidonic acid-induced platelet aggregation, but only 0.6 mg/kg acetylsalicylic acid, or higher, decreased the plasma levels of 6-keto-prostaglandin-F1α, the stable metabolite of prostacyclin. When given with clopidogrel, laser injury-induced arterial thrombi were significantly larger with the 0.6 mg/kg dose of acetylsalicylic acid than with the 0.15 mg/kg dose. Thrombi in mice treated with clopidogrel and the 0.15 mg/kg dose of acetylsalicylic acid were smaller than in mice treated with clopidogrel alone, suggesting that acetylsalicylic acid can add to the antithrombotic effect of clopidogrel but that higher doses of acetylsalicylic acid blunt the antithrombotic effect of clopidogrel. Conclusions- These findings support the use of lower, prostacyclin-preserving, doses of acetylsalicylic acid in conjunction with clopidogrel.
Collapse
Affiliation(s)
- Ran Ni
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
| | - Nima Vaezzadeh
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
| | - Ji Zhou
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
| | - Jeffrey I Weitz
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
| | - Marco Cattaneo
- Medicina 3, Dipartimento di Scienze della Salute, Ospedale San Paolo, Università degli Studi di Milano, Italy (M.C.)
| | - Peter L Gross
- From the Department of Medicine, McMaster University, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (R.N., N.V., J.Z., J.I.W., P.L.G.)
| |
Collapse
|
20
|
Laboratory Monitoring of Antiplatelet Therapy. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
21
|
Frelinger AL. Platelet Function Testing in Clinical Research Trials. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00037-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
22
|
|
23
|
Ramström S. Arachidonic acid causes lysis of blood cells and ADP-dependent platelet activation responses in platelet function tests. Platelets 2018; 30:1001-1007. [PMID: 30580677 DOI: 10.1080/09537104.2018.1557614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The use of arachidonic acid (AA) to stimulate platelets is considered as a specific approach to study aspirin treatment efficacy. However, very high concentrations of AA are used, and it has been previously reported that AA can induce cell lysis in other settings. Several clinical studies have reported decreased responses to AA in whole blood tests in the presence of clopidogrel. Our aim was to investigate whether unspecific effects contribute to AA-induced aggregation and platelet activation in light transmission aggregometry (LTA) in platelet-rich plasma (PRP), and in assays using whole blood, multiple electrode aggregometry (MEA, Multiplate®), and flow cytometry. We report that cell lysis, especially of red blood cells, does occur at concentrations of AA used in the clinical tests and that ADP is very important for the AA-induced platelet activation responses. In flow cytometry, very limited platelet activation was detected before reaching AA concentrations in the millimolar range, where cell lysis also occurred, making it problematic to develop a reliable flow cytometry assay using AA as reagent. We conclude that cell lysis and ADP release contribute to AA-induced platelet responses, most markedly in whole blood assays. This finding could potentially explain some differences between studies comparing methods using whole blood and PRP and also how clopidogrel treatment could influence AA-induced aggregation results in previously published studies. Our findings highlight some issues with AA as reagent for platelet activation, which also have an impact on how platelet activation assays using AA should be interpreted.
Collapse
Affiliation(s)
- Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping , Sweden.,Cardiovascular Research Centre, School of Medical Sciences, Örebro University , Örebro , Sweden
| |
Collapse
|
24
|
Chung CJ, Kirtane AJ, Zhang Y, Witzenbichler B, Weisz G, Stuckey TD, Brodie BR, Rinaldi MJ, Neumann FJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Mazzaferri EL, Mehran R, Stone GW. Impact of high on-aspirin platelet reactivity on outcomes following successful percutaneous coronary intervention with drug-eluting stents. Am Heart J 2018; 205:77-86. [PMID: 30196181 DOI: 10.1016/j.ahj.2018.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether high on-aspirin platelet reactivity (HAPR) confers an increased risk of adverse outcomes after percutaneous coronary intervention (PCI) remains unclear. We sought to examine the specific relationship between HAPR and clinical outcomes in ADAPT-DES. METHODS A total of 8,526 "all-comer" patients in the ADAPT-DES registry who underwent placement of drug-eluting stents (DES) and were treated with aspirin and clopidogrel were assessed to measure platelet reactivity. HAPR was characterized as ≥550 aspirin reaction units and high on-clopidogrel platelet reactivity as >208 P2Y12 reaction units. Univariable and propensity-adjusted multivariable analyses were used to assess the relationship between HAPR and clinical outcomes. RESULTS HAPR was present in 478 (5.6%) patients. Patients with HAPR were older and had more comorbid illnesses and more complex coronary anatomy. During 2-year follow-up, HAPR was not associated with increased rates of major adverse cardiac events (MACE), stent thrombosis, myocardial infarction, or all-cause mortality. In propensity-adjusted multivariable analyses, HAPR was not an independent predictor of MACE after successful PCI (multivariable adjusted hazard ratio: 1.04; 95% CI 0.64-1.69, P = .87). Nor was HAPR associated with reduced bleeding. Even among patients with concomitant high on-clopidogrel platelet reactivity, HAPR was not associated with worse ischemic outcomes (adjusted hazard ratio for 2-year MACE: 1.06; 95% CI 0.55-2.00, P = .87). CONCLUSIONS HAPR was infrequently present in a large registry of patients undergoing PCI. There was no clear relationship between HAPR and 2-year clinical outcomes. Investigations of antiplatelet regimens without aspirin after DES implantation are ongoing and should inform future management of patients undergoing PCI.
Collapse
Affiliation(s)
- Christine J Chung
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Ajay J Kirtane
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Yiran Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | | | - Giora Weisz
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; Montefiore Medical Center, Bronx, NY
| | - Thomas D Stuckey
- LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, NC
| | - Bruce R Brodie
- LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, NC
| | | | - Franz-Josef Neumann
- Division of Cardiology and Angiology II, Heart Center University of Freiburg, Bad Krozingen, Germany
| | | | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - David A Cox
- CVA Brookwood Baptist Hospital, Birmingham, AL
| | - Peter L Duffy
- Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, NC
| | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregg W Stone
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY.
| |
Collapse
|
25
|
Bonaventura A, Liberale L, Montecucco F. Aspirin in primary prevention for patients with diabetes: Still a matter of debate. Eur J Clin Invest 2018; 48:e13001. [PMID: 30011059 DOI: 10.1111/eci.13001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/15/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with diabetes are at high cardiovascular (CV) risk due to an exaggerated platelet activation and aggregation. In the first 2000s low-dose aspirin was first recommended for primary prevention, but then re-discussed. METHODS This short narrative review, based on the material searched for and obtained via PubMed up to February 2018, aims at clarifying this controversial topic. RESULTS The JPAD2 study has been designed to evaluate the occurrence of any CV event in a cohort of patients with diabetes and concluded that low-dose aspirin did not influence the risk for CV events while increasing the risk for gastrointestinal (GI) bleeding. Reasons for this result can be found in the role of diabetic platelets, which are known to be hyperreactive, thus producing intensified adhesion, activation, and aggregation. In this setting, other associated metabolic conditions can concur to enhance platelet adhesion and activation. Aspirin resistance has been often considered a guilty actor, although many mechanisms have been mistaken for true aspirin resistance, such as patient poor compliance, inadequate dosing, drug interactions, and high-platelet turnover. However, the mere presence of diabetes is not likely to give a net benefit for CV protection with respect to GI bleeding. CONCLUSION It appears advisable to follow current guidelines addressing first of all classical risk factors and evaluate aspirin therapy in primary prevention only for patients with type 1 or 2 diabetes at increased CV risk and no risk for GI bleeding. Anyway, additional clinical trials are needed to address the current topic.
Collapse
Affiliation(s)
- Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Luca Liberale
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy.,Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| |
Collapse
|
26
|
Harrison P, Bethel MA, Kennedy I, Dinsdale R, Coleman R, Holman RR. Comparison of nine platelet function tests used to determine responses to different aspirin dosages in people with type 2 diabetes. Platelets 2018; 30:521-529. [DOI: 10.1080/09537104.2018.1478402] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paul Harrison
- Institute of Inflammation and Ageing, University of Birmingham Medical School, Birmingham, UK
| | | | - Irene Kennedy
- Diabetes Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Robert Dinsdale
- Institute of Inflammation and Ageing, University of Birmingham Medical School, Birmingham, UK
| | - Ruth Coleman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Rury R. Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| |
Collapse
|
27
|
Massimi I, Alemanno L, Guarino ML, Guerriero R, Frati L, Biasucci L, Pulcinelli FM. MiR-21 role in aspirin-dependent PPARα and multidrug resistance protein 4 upregulation. Res Pract Thromb Haemost 2018; 2:596-606. [PMID: 30046765 PMCID: PMC6046603 DOI: 10.1002/rth2.12104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A mechanism involved in high on-aspirin treatment residual platelet reactivity is platelet multidrug resistance protein 4 (MRP4) overexpression. Aspirin enhances platelet MRP4 expression with a PPARα-dependent mechanism and reduces miR-21 expression that, in turn, downregulates PPARα expression. OBJECTIVE The aim of our study was to verify the relationship between miR-21 and MRP4-PPARα levels induced by aspirin treatment. METHODS We evaluated the changes in MRP4-PPARα, mRNA, MRP4 protein, and miR-21 expression induced by aspirin in: (i) in vitro-treated megakaryoblastic cell line (DAMI), (ii) primary megakaryocytes cultures and derived platelets, (iii) healthy volunteers' platelets treated with aspirin, and (iv) aspirinated patients (aspirin-treated patients) and in a control population (control). RESULTS We observed an aspirin-induced reverse relationship between the expression of miR-21 and PPARα-MRP4. In DAMI cells the miR-21 mimic transfection reduces PPARα and MRP4 expression, even if cells were treated with aspirin after transfection. MiR-21 inhibitor transfection induces PPARα and MRP4 expression that are not enhanced by aspirin treatment. In human megakaryocytes, aspirin treatment lead to a miR-21 downregulation and a MRP4 upregulation and this trend is confirmed in derived platelets. In aspirin-treated volunteers, an inverse relationship between miR-21 and MRP4 platelet expression was found after aspirin treatment. A similar negative relationship was found in aspirin-treated patients vs the control population. CONCLUSION The results reported in this study provide information that aspirin induces the modulation of platelet miR-21 expression levels and this modulation can be responsible for MRP4 enhancement in circulating platelets.
Collapse
Affiliation(s)
- Isabella Massimi
- Department of Experimental MedicineSapienza‐University of RomeRomeItaly
| | - Laura Alemanno
- Department of Experimental MedicineSapienza‐University of RomeRomeItaly
| | - Maria L. Guarino
- Department of Experimental MedicineSapienza‐University of RomeRomeItaly
| | - Raffaella Guerriero
- Department of Cardiovascular, Dysmetabolic and Aging‐Associated DiseasesIstituto Superiore di SanitàRomeItaly
| | | | - Luigi Biasucci
- Department of CardiologyCatholic University of the Sacred Heart of RomeRomeItaly
| | | |
Collapse
|
28
|
The Aspirin Regimens in Essential Thrombocythemia (ARES) phase II randomized trial design: Implementation of the serum thromboxane B 2 assay as an evaluation tool of different aspirin dosing regimens in the clinical setting. Blood Cancer J 2018; 8:49. [PMID: 29880847 PMCID: PMC5992153 DOI: 10.1038/s41408-018-0078-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/23/2018] [Accepted: 04/03/2018] [Indexed: 12/12/2022] Open
Abstract
Once-daily (od), low-dose aspirin (75–100 mg) is recommended to reduce the thrombotic risk of patients with essential thrombocytemia (ET). This practice is based on data extrapolated from other high-risk patients and an aspirin trial in polycythemia vera, with the assumption of similar aspirin pharmacodynamics in the two settings. However, the pharmacodynamics of low-dose aspirin is impaired in ET, reflecting accelerated renewal of platelet cyclooxygenase (COX)-1. ARES is a parallel-arm, placebo-controlled, randomized, dose-finding, phase II trial enrolling 300 ET patients to address two main questions. First, whether twice or three times 100 mg aspirin daily dosing is superior to the standard od regimen in inhibiting platelet thromboxane (TX)A2 production, without inhibiting vascular prostacyclin biosynthesis. Second, whether long-term persistence of superior biochemical efficacy can be safely maintained with multiple vs. single dosing aspirin regimen. Considering that the primary study end point is serum TXB2, a surrogate biomarker of clinical efficacy, a preliminary exercise of reproducibility and validation of this biomarker across all the 11 participating centers was implemented. The results of this preliminary phase demonstrate the importance of controlling reproducibility of biomarkers in multicenter trials and the feasibility of using serum TXB2 as a reliable end point for dose-finding studies of novel aspirin regimens.
Collapse
|
29
|
van Diemen J, Fuijkschot W, Spit K, van Reuler A, Bonten T, Numans M, van der Bom J, Smulders Y, Thijs A. Influence of pre-analytical time and temperature conditions on serum thromboxane B 2 levels. Thromb Res 2018; 163:1-5. [DOI: 10.1016/j.thromres.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/22/2017] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
|
30
|
Schrör K. Why we should not skip aspirin in cardiovascular prevention. Hamostaseologie 2018; 36:33-43. [DOI: 10.5482/hamo-14-10-0048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/06/2015] [Indexed: 01/05/2023] Open
Abstract
SummarySince more than 20 years, aspirin is an approved and established first-line antiplatelet medication in cardiovascular prevention. This is partially due to ist unique mode of action which is not shared with any other antiplatelet agent as well by the reliability of its pharmacological efficacy: inhibition of platelet COX-1 and subsequent thromboxane formation in almost every patient. Aspirin acts synergistic with ADP-antagonists in dual antiplatelet therapy of acute coronary syndroms (ACS) and percutaneous coronary interventions (PCI) and is also approved for long-term secondary prevention. Patients with atrial fibrillation are an exception and benefit more from anticoagulants. After the introduction of the new oral anticoagulants (NOACs), i.e. direct inhibitors of factor Xa or thrombin formation, there is a renewed discussion about the role of antiplatelet agents, specifically if additional dual antiplatelet treatment is still necessary for an optimum clinical effect or whether one component, such as aspirin might be skipped in favor of other classes of oral antiplatelet agents, such as ADP-antagonists. The available data are insufficient to recommend this because of a low number of studies and a still uncertain benefit/ risk (bleeding) ratio. More research on aspirin as a chemopreventive appears also to be necessary and is going on, in particular in individuals at high-risk for vascular thrombotic diseases (diabetics, preeclampsia, venous thrombembolism).
Collapse
|
31
|
Wingrove JA, Fitch K, Rhees B, Rosenberg S, Voora D. Peripheral blood gene expression signatures which reflect smoking and aspirin exposure are associated with cardiovascular events. BMC Med Genomics 2018; 11:1. [PMID: 29329538 PMCID: PMC5767057 DOI: 10.1186/s12920-017-0318-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/21/2017] [Indexed: 11/10/2022] Open
Abstract
Background Cardiovascular disease and its sequelae are major causes of global mortality, and better methods are needed to identify patients at risk for future cardiovascular events. Gene expression analysis can inform on the molecular underpinnings of risk factors for cardiovascular events. Smoking and aspirin have known opposing effects on platelet reactivity and MACE, however their effects on each other and on MACE are not well described. Methods We measured peripheral blood gene expression levels of ITGA2B, which is upregulated by aspirin and correlates with platelet reactivity on aspirin, and a 5 gene validated smoking gene expression score (sGES) where higher expression correlates with smoking status, in participants from the previously reported PREDICT trial (NCT 00500617). The primary outcome was a composite of death, myocardial infarction, and stroke/TIA (MACE). We tested whether selected genes were associated with MACE risk using logistic regression. Results Gene expression levels were determined in 1581 subjects (50.5% female, mean age 60.66 +/−11.46, 18% self-reported smokers); 3.5% of subjects experienced MACE over 12 months follow-up. Elevated sGES and ITGA2B expression were each associated with MACE (odds ratios [OR] =1.16 [95% CI 1.10–1.31] and 1.42 [95% CI 1.00–1.97], respectively; p < 0.05). ITGA2B expression was inversely associated with self-reported smoking status and the sGES (p < 0.001). A logistic regression model combining sGES and ITGA2B showed better performance (AIC = 474.9) in classifying MACE subjects than either alone (AIC = 479.1, 478.2 respectively). Conclusion Gene expression levels associated with smoking and aspirin are independently predictive of an increased risk of cardiovascular events. Electronic supplementary material The online version of this article (10.1186/s12920-017-0318-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Karen Fitch
- CardioDx, Inc, 600 Saginaw Dr., Redwood City, CA, 94063, USA
| | - Brian Rhees
- CardioDx, Inc, 600 Saginaw Dr., Redwood City, CA, 94063, USA
| | | | - Deepak Voora
- Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University, 101 Science Drive, 2187 CIEMAS, Durham, NC, 27708, UK.
| |
Collapse
|
32
|
Olechowski B, Khanna V, Mariathas M, Ashby A, Dalton RT, Nordon I, Englyst N, Harris S, Nicholas Z, Thayalasamy K, Mahmoudi M, Curzen N. Changes in platelet function with inflammation in patients undergoing vascular surgery. Platelets 2017; 30:190-198. [DOI: 10.1080/09537104.2017.1392498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Bartosz Olechowski
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vikram Khanna
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Mariathas
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Ashby
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard T Dalton
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Nordon
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicola Englyst
- Institute of Developmental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Scott Harris
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zoe Nicholas
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kala Thayalasamy
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
33
|
Trenk D, Schrör K, Gawaz M, Kristensen SD, Storey RF, Huber K, Siller-Matula JM. How to improve the concept of individualised antiplatelet therapy with P2Y12 receptor inhibitors – is an algorithm the answer? Thromb Haemost 2017; 113:37-52. [DOI: 10.1160/th14-03-0238] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 07/22/2014] [Indexed: 01/03/2023]
Abstract
SummaryWithin the past decade, high on-treatment platelet reactivity (HTPR) on clopidogrel and its clinical implications have been frequently discussed. Although it has been previously assumed that HTPR is a phenomenon occurring only in patients treated with clopidogrel, recent data show that HTPR might also occur during treatment with prasugrel or ticagrelor in the acute phase of ST-elevation myocardial infarction. Moreover, it has been postulated that there is a therapeutic window for P2Y12 receptor blockers, thus indicating that HTPR is associated with thrombotic events whereas low on-treatment platelet reactivity (LTPR) is associated with bleeding events. The current paper focuses on tools to identify risk factors for HTPR (pharmacogenomic testing, clinical scoring and drug-drug interactions) and on the use of platelet function testing in order to identify patients who might not respond adequately to clopidogrel. The majority of recent clinical randomised trials have not supported the hypothesis that platelet function testing and tailored antiplatelet therapy are providing a favourable clinical outcome. These trials, mainly performed in low-to-moderate risk patients, will be reviewed and discussed. Finally, an algorithm based on current knowledge is suggested, which might be of use for design of clinical trials.
Collapse
|
34
|
Hosokawa K, Ohnishi T, Sameshima H, Miura N, Ito T, Koide T, Maruyama I. Analysing responses to aspirin and clopidogrel by measuring platelet thrombus formation under arterial flow conditions. Thromb Haemost 2017. [DOI: 10.1160/th12-06-0441] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
SummaryHigh residual platelet aggregability and circulating platelet-monocyte aggregates in patients administered aspirin and clopidogrel are associated with ischaemic vascular events. To determine the relevance of these factors with residual thrombogenicity, we measured platelet thrombus formation using a microchip-based flow-chamber system in cardiac patients receiving aspirin and/or clopidogrel, and evaluated its correlation with agonist-inducible platelet aggregation and platelet-monocyte aggregates. Platelet thrombus formation was analysed by measuring flow pressure changes due to the occlusion of micro-capillaries and was quantified by calculating AUC10 (area under the flow pressure curve). The growth and stability of platelet thrombi that formed inside microchips at shear rates of 1000, 1500, and 2000 s-1 were markedly reduced in patients receiving aspirin and/or thienopyridine compared to healthy controls (n=33). AUC10 values of aspirin therapy patients (n=20) were significantly lower and higher than those of healthy controls and dual antiplatelet therapy patients (n=19), respectively, and showed relatively good correlations with collagen-induced platelet aggregation and platelet-monocyte aggregates at 1000 and 1500 s-1 (r
s
>0.59, p<0.01). In contrast, AUC10 in dual antiplatelet therapy patients was significantly correlated with ADP-induced platelet aggregation at all examined shear rates (r
s
>0.59, p<0.01), but did not correlate with collagen-induced aggregation. Aspirin monotherapy patients with high residual platelet thrombogenicity also exhibited significant elevations in both collagen-induced platelet aggregation and platelet-monocyte aggregates. Our results, although preliminary, suggest that residual platelet thrombogenicity in aspirin-treated patients is associated with either collagen-induced platelet aggregation or circulating platelet-monocyte aggregates, but it is predominantly dependent on ADP-induced platelet aggregation in patients receiving dual antiplatelet therapy.
Collapse
|
35
|
Spectre G, Arnetz L, Östenson CG, Brismar K, Li N, Hjemdahl P. Twice daily dosing of aspirin improves platelet inhibition in whole blood in patients with type 2 diabetes mellitus and micro- or macrovascular complications. Thromb Haemost 2017; 106:491-9. [DOI: 10.1160/th11-04-0216] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 06/17/2011] [Indexed: 01/10/2023]
Abstract
SummaryThe efficacy of low-dose aspirin in type 2 diabetes mellitus (T2DM) has been questioned. We tested if twice daily dosing of aspirin would be more effective in T2DM, possibly due to increased platelet turnover. A randomised cross-over study compared 75 mg aspirin OD, 75 mg BID and 320 mg OD (≥2 week treatment periods) in 25 patients with T2DM and micro- or macrovascular complications. Platelet responses were examined by impedance aggregometry (WBA) and the IMPACT-R aspirin test in whole blood, light transmittance aggregometry in plateletrich plasma (LTA), and urinary 11-dehydro-thromboxane B2 (TxM). Aspirin 75 mg BID decreased arachidonic acid (AA)-induced WBA compared to 75 mg OD (9.7 ± 4.5 vs. 12.6 ± 3.5 ohm; p=0.003) or to 320 mg OD (11.5 ± 4.2 Ohms; p=0.049). WBA responses to collagen were similarly attenuated by BID or high dosing (by 12–14%; p=0.02 for both). The IMPACT-R showed a better response to 75 mg BID compared to 75 mg OD (p=0.049), but not to 320 mg OD. AA-induced aggregation by LTA was <6.5% on all occasions, with no differences between aspirin dosages. TxM was reduced after 320 mg OD (p=0.002), but not 75 mg BID (p=0.07). Reticulated platelets were highly correlated with mean platelet volume (MPV; r2=0.74, p<0.0001). Both markers for platelet turnover were correlated with AA-induced WBA, but neither identified patients who benefited from BID dosing dependably. In conclusion, twice daily dosing improved laboratory responses to aspirin in high risk T2DM patients. Studies of whether BID dosing of aspirin can improve clinical outcomes in such patients are of interest.
Collapse
|
36
|
Cattaneo M. High on-treatment platelet reactivity – definition and measurement. Thromb Haemost 2017; 109:792-8. [DOI: 10.1160/th12-10-0758] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 01/23/2013] [Indexed: 12/31/2022]
Abstract
SummaryIn the last decade, several studies revealed inter-patient response variability to antiplatelet agents: patients who display negligible or no responses to these drugs are considered poor responders, or “resistant” to treatment. In order to identify poor responders to an antiplatelet drug, laboratory tests of platelet function that specifically explore the platelet activation pathway that is targeted by the drug should be utilised. In addition, they should be performed both at baseline and during treatment: however, most studies explored platelet function during antiplatelet treatment, in order to identify those patients with “high on-treatment platelet reactivity” (HPR), which exposes them to increased risk of major adverse cardiovascular events (MACE). Many tests of platelet function have been used, most of which are able to identify patients at risk of MACE. Unfortunately, universal cut-off values for HPR have not been clearly established yet. In addition, the concordance among different tests in the identification of patients at risk is very poor and the most effective and safe treatment for patients at risk is still unknown.
Collapse
|
37
|
Saris A, van Oostrom M, Snoep J, Rosendaal F, Zwaginga J, Eikenboom J, van der Meer P, van der Bom J, Bonten T. Effect of aspirin intake at bedtime versus on awakening on circadian rhythm of platelet reactivity. Thromb Haemost 2017; 112:1209-18. [DOI: 10.1160/th14-05-0453] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/10/2014] [Indexed: 02/02/2023]
Abstract
SummaryThe risk of acute cardiovascular events is highest during morning hours, and platelet activity peaks during morning hours. The effect of timing of aspirin intake on circadian rhythm and morning peak of platelet reactivity is not known. It was our objective to evaluate the effect of timing of aspirin intake on circadian rhythm and morning peak of platelet reactivity. A randomised open-label cross-over trial in healthy subjects (n=14) was conducted. Participants used acetylsalicylic acid (80 mg) on awakening or at bedtime for two periods of two weeks, separated by a four-week wash-out period. At the end of both periods blood was drawn every 3 hours to measure COX-1-dependent (VerifyNow- Aspirin; Serum Thromboxane B2 [STxB2]) and COX-1-independent (flow cytometry surface CD62p expression; microaggregation) platelet activity. VerifyNow platelet reactivity over the whole day was similar with intake on awakening and at bedtime (mean difference: –9 [95 % confidence interval (CI) –21 to 4]). However, the morning increase in COX-1-dependent platelet activity was reduced by intake of aspirin at bedtime compared with on awakening (mean difference VerifyNow: –23 Aspirin Reaction Units [CI –50 to 4]; STxB2: –1.7 ng/ml [CI –2.7 to –0.8]). COX-1-independent assays were not affected by aspirin intake or its timing. Low-dose aspirin taken at bedtime compared with intake on awakening reduces COX-1-dependent platelet reactivity during morning hours in healthy subjects. Future clinical trials are required to investigate whether simply switching to aspirin intake at bedtime reduces the risk of cardiovascular events during the high risk morning hours.
Collapse
|
38
|
|
39
|
Emani S, Zurakowski D, Mulone M, DiNardo JA, Trenor CC, Emani SM. Platelet testing to guide aspirin dose adjustment in pediatric patients after cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1723-1730. [DOI: 10.1016/j.jtcvs.2017.06.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 03/21/2017] [Accepted: 06/13/2017] [Indexed: 12/19/2022]
|
40
|
Chen HY, Chou P. PFA-100-measured aspirin resistance is the predominant risk factor for hospitalized cardiovascular events in aspirin-treated patients: A 5-year cohort study. J Clin Pharm Ther 2017; 43:249-255. [PMID: 29055181 DOI: 10.1111/jcpt.12643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/02/2017] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Aspirin therapy is the clinical gold standard for the prevention of cardiovascular events. However, cardiovascular events still develop in some patients undergoing aspirin therapy. Many laboratory methods exist for measuring aspirin resistance. Using the platelet Function Analyzer (PFA)-100 system, we aimed to determine the effect of aspirin resistance on hospitalized cardiovascular events (hCVE) in a 5-year follow-up cohort. We also sought to determine the impact of aspirin resistance on the relationship between common cardiovascular risk factors and cardiovascular hospitalization. METHOD Aspirin resistance was evaluated in aspirin-treated patients from the outpatient department. A total of 465 patients during a 5-year follow-up period were included in this study. The primary endpoint of the study was hospitalization for any acute cardiovascular event. The prevalence and associated risk factors of acute cardiovascular events were evaluated. RESULTS AND DISCUSSION Aspirin resistance was prevalent in 91 (20.0%) of 465 patients. Prior hospitalization history of cardiovascular events was highly associated with aspirin resistance (P = .001). At the 5-year follow-up, cardiovascular events were found to have developed in 11 patients (8 stroke and 3 myocardial infarction) who exhibited aspirin resistance (12.1%) and in 9 (4 stroke and 5 myocardial infarction) patients who did not exhibit aspirin resistance (2.4%) (P < .001). At the 5-year follow-up, multivariate logistic regression analysis results showed a strong association between aspirin resistance and cardiovascular events (adjusted odds ratio 4.28; 95% CI: 1.64-11.20; P = .03). WHAT IS NEW AND CONCLUSION PFA-100 measurements of aspirin resistance correlate with hCVE, as evidenced by both the past medical history and the 5-year follow-up. The logistic regression analysis results showed that aspirin resistance plays a larger role in hospitalized cardiovascular disease than do other cardiovascular risk factors.
Collapse
Affiliation(s)
- H Y Chen
- Division of Cardiology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - P Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| |
Collapse
|
41
|
Larsen SB, Grove EL, Neergaard-Petersen S, Würtz M, Hvas AM, Kristensen SD. Reduced Antiplatelet Effect of Aspirin Does Not Predict Cardiovascular Events in Patients With Stable Coronary Artery Disease. J Am Heart Assoc 2017; 6:JAHA.117.006050. [PMID: 28780510 PMCID: PMC5586446 DOI: 10.1161/jaha.117.006050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Increased platelet aggregation during antiplatelet therapy may predict cardiovascular events in patients with coronary artery disease. The majority of these patients receive aspirin monotherapy. We aimed to investigate whether high platelet‐aggregation levels predict cardiovascular events in stable coronary artery disease patients treated with aspirin. Methods and Results We included 900 stable coronary artery disease patients with either previous myocardial infarction, type 2 diabetes mellitus, or both. All patients received single antithrombotic therapy with 75 mg aspirin daily. Platelet aggregation was evaluated 1 hour after aspirin intake using the VerifyNow Aspirin Assay (Accriva Diagnostics) and Multiplate Analyzer (Roche; agonists: arachidonic acid and collagen). Adherence to aspirin was confirmed by serum thromboxane B2. The primary end point was the composite of nonfatal myocardial infarction, ischemic stroke, and cardiovascular death. At 3‐year follow‐up, 78 primary end points were registered. The primary end point did not occur more frequently in patients with high platelet‐aggregation levels (first versus fourth quartile) assessed by VerifyNow (hazard ratio: 0.5 [95% CI, 0.3–1.1], P=0.08) or Multiplate using arachidonic acid (hazard ratio: 1.0 [95% CI, 0.5–2.1], P=0.92) or collagen (hazard ratio: 1.4 [95% CI, 0.7–2.8], P=0.38). Similar results were found for the composite secondary end point (nonfatal myocardial infarction, ischemic stroke, stent thrombosis, and all‐cause death) and the single end points. Thromboxane B2 levels did not predict any end points. Renal insufficiency was the only clinical risk factor predicting the primary and secondary end points. Conclusions This study is the largest to investigate platelet aggregation in stable coronary artery disease patients receiving aspirin as single antithrombotic therapy. We found that high platelet‐aggregation levels did not predict cardiovascular events.
Collapse
Affiliation(s)
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Faculty of Health, Institute of Clinical Medicine Aarhus University, Aarhus, Denmark
| | | | - Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Faculty of Health, Institute of Clinical Medicine Aarhus University, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark .,Faculty of Health, Institute of Clinical Medicine Aarhus University, Aarhus, Denmark
| |
Collapse
|
42
|
Mao G, Songdej N, Voora D, Goldfinger LE, Del Carpio-Cano FE, Myers RA, Rao AK. Transcription Factor RUNX1 Regulates Platelet PCTP (Phosphatidylcholine Transfer Protein): Implications for Cardiovascular Events: Differential Effects of RUNX1 Variants. Circulation 2017; 136:927-939. [PMID: 28676520 DOI: 10.1161/circulationaha.116.023711] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 06/16/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND PCTP (phosphatidylcholine transfer protein) regulates the intermembrane transfer of phosphatidylcholine. Higher platelet PCTP expression is associated with increased platelet responses on activation of protease-activated receptor 4 thrombin receptors noted in black subjects compared with white subjects. Little is known about the regulation of platelet PCTP. Haplodeficiency of RUNX1, a major hematopoietic transcription factor, is associated with thrombocytopenia and impaired platelet responses on activation. Platelet expression profiling of a patient with a RUNX1 loss-of-function mutation revealed a 10-fold downregulation of the PCTP gene compared with healthy controls. METHODS We pursued the hypothesis that PCTP is regulated by RUNX1 and that PCTP expression is correlated with cardiovascular events. We studied RUNX1 binding to the PCTP promoter using DNA-protein binding studies and human erythroleukemia cells and promoter activity using luciferase reporter studies. We assessed the relationship between RUNX1 and PCTP in peripheral blood RNA and PCTP and death or myocardial infarction in 2 separate patient cohorts (587 total patients) with cardiovascular disease. RESULTS Platelet PCTP protein in the patient was reduced by ≈50%. DNA-protein binding studies showed RUNX1 binding to consensus sites in ≈1 kB of PCTP promoter. PCTP expression was increased with RUNX1 overexpression and reduced with RUNX1 knockdown in human erythroleukemia cells, indicating that PCTP is regulated by RUNX1. Studies in 2 cohorts of patients showed that RUNX1 expression in blood correlated with PCTP gene expression; PCTP expression was higher in black compared with white subjects and was associated with future death/myocardial infarction after adjustment for age, sex, and race (odds ratio, 2.05; 95% confidence interval 1.6-2.7; P<0.0001). RUNX1 expression is known to initiate at 2 alternative promoters, a distal P1 and a proximal P2 promoter. In patient cohorts, there were differential effects of RUNX1 isoforms on PCTP expression with a negative correlation in blood between RUNX1 expressed from the P1 promoter and PCTP expression. CONCLUSIONS PCTP is a direct transcriptional target of RUNX1. PCTP expression is associated with death/myocardial infarction in patients with cardiovascular disease. RUNX1 regulation of PCTP may play a role in the pathogenesis of platelet-mediated cardiovascular events.
Collapse
Affiliation(s)
- Guangfen Mao
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.)
| | - Natthapol Songdej
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.)
| | - Deepak Voora
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.)
| | - Lawrence E Goldfinger
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.)
| | - Fabiola E Del Carpio-Cano
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.)
| | - Rachel A Myers
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.)
| | - A Koneti Rao
- From Sol Sherry Thrombosis Research Center (G.M., N.S., F.E.D.C.-C., L.E.G., A.K.R.), Hematology Section, Department of Medicine (N.S., A.K.R.), and Department of Anatomy and Cell Biology (L.E.G.), Lewis Katz School of Medicine at Temple University, Philadelphia, PA; and Duke Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University, Durham, NC (D.V., R.A.M.).
| |
Collapse
|
43
|
Enteric Coating and Aspirin Nonresponsiveness in Patients With Type 2 Diabetes Mellitus. J Am Coll Cardiol 2017; 69:603-612. [DOI: 10.1016/j.jacc.2016.11.050] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/24/2016] [Accepted: 11/07/2016] [Indexed: 12/11/2022]
|
44
|
Olechowski B, Ashby A, Mariathas M, Khanna V, Mahmoudi M, Curzen N. Is arachidonic acid stimulation really a test for the response to aspirin? Time to think again? Expert Rev Cardiovasc Ther 2016; 15:35-46. [DOI: 10.1080/14779072.2017.1266255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Bartosz Olechowski
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Ashby
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Mariathas
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vikram Khanna
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
45
|
Santos MT, Moscardó A, Latorre A, Cortina B, Vallés J. The time between venepuncture and blood incubation is critical for serum thromboxane B2 synthesis. Platelets 2016; 28:310-311. [PMID: 27897081 DOI: 10.1080/09537104.2016.1246719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- María Teresa Santos
- a Unit of Hemostasia, Thrombosis, Atherosclerosis and Vascular Biology , Health Research Institute La Fe , Valencia , Spain
| | - Antonio Moscardó
- a Unit of Hemostasia, Thrombosis, Atherosclerosis and Vascular Biology , Health Research Institute La Fe , Valencia , Spain
| | - Ana Latorre
- a Unit of Hemostasia, Thrombosis, Atherosclerosis and Vascular Biology , Health Research Institute La Fe , Valencia , Spain
| | - Belén Cortina
- a Unit of Hemostasia, Thrombosis, Atherosclerosis and Vascular Biology , Health Research Institute La Fe , Valencia , Spain
| | - Juana Vallés
- a Unit of Hemostasia, Thrombosis, Atherosclerosis and Vascular Biology , Health Research Institute La Fe , Valencia , Spain
| |
Collapse
|
46
|
Massimi I, Lotti LV, Temperilli F, Mancone M, Sardella G, Calcagno S, Turriziani O, Frati L, Pulcinelli FM. Enhanced platelet MRP4 expression and correlation with platelet function in patients under chronic aspirin treatment. Thromb Haemost 2016; 116:1100-1110. [PMID: 27683757 DOI: 10.1160/th16-04-0316] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/23/2016] [Indexed: 11/05/2022]
Abstract
Platelet multidrug resistance protein4 (MRP4)-overexpression has a role in reducing aspirin action. Aspirin in vivo treatment enhances platelet MRP4 expression and MRP4 mediated transport inhibition reduces platelet function and delays thrombus formation. The aim of our work was to verify whether MRP4 expression is enhanced in platelets obtained from patients under chronic aspirin treatment and whether it correlates with residual platelet reactivity. We evaluated changes on mRNA and protein-MRP4 expression and platelet aggregation in four populations: healthy volunteers (HV), aspirin-free control population (CTR), patients who started the treatment less than one month ago (ASA<1 month patients) and aspirinated patients who started the treatment more than two months ago (ASA>2 months patients). In platelets obtained from ASA>2 months patients, it was found a statistically significant MRP4 enhancement of both mRNA and protein expression compared to HV, CTR and ASA<1 month patients. Platelets obtained from ASA>2 months patients that present high levels of platelet MRP4, have higher serum TxB2 levels and collagen-induced platelet aggregation compared to patient with low levels of MRP4 in platelets. In addition collagen induced platelet aggregation is higher in in vitro aspirinated platelets obtained from patients with high levels of MRP4 patients compared to those obtained from patients with low MRP4 levels. We can assert that, in patients under chronic aspirin treatment, platelets that present high MRP4 levels have an increase of residual platelet reactivity, which is due in part to incomplete COX-1 inhibition, and in part to COX-1-independent mechanism.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Fabio M Pulcinelli
- Fabio M. Pulcinelli, MD, Department of Experimental Medicine, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy, Tel.: +39 06 49973002, Fax: +39 06 4452955, E-mail:
| |
Collapse
|
47
|
Szczeklik W, Stodółkiewicz E, Rzeszutko M, Tomala M, Chrustowicz A, Żmudka K, Sanak M. Urinary 11-Dehydro-Thromboxane B2 as a Predictor of Acute Myocardial Infarction Outcomes: Results of Leukotrienes and Thromboxane In Myocardial Infarction (LTIMI) Study. J Am Heart Assoc 2016; 5:JAHA.116.003702. [PMID: 27481134 PMCID: PMC5015290 DOI: 10.1161/jaha.116.003702] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Urinary 11-dehydro-thromboxane (TX)B2 has been described as a potential predictive biomarker of major adverse cardiovascular events (MACEs) in high cardiac risk patients. This part of LTIMI (Leukotrienes and Thromboxane In Myocardial Infarction) study aimed to evaluate the relationship between 11-dehydro-TXB2 and MACEs in patients with acute myocardial infarction (AMI). METHODS AND RESULTS LTIMI was an observational, prospective study in 180 consecutive patients with AMI type 1 referred for primary percutaneous coronary intervention. On admission and at follow-up visits (1 month, 1 year), 11-dehydro-TXB2 was measured in urinary samples by using high-performance liquid chromatography-tandem mass spectrometry. The primary outcome was occurrence of composite MACEs during 1-year after AMI. Left ventricular ejection fraction was assessed in echocardiography on admission and at 1-year follow-up. Analyses of 11-dehydro-TXB2 (pg/mg creatinine) were performed on log-transformed data and expressed as median with IQR (Q1-Q3). 11-Dehydro-TXB2 level on admission was 7.39 (6.85-8.01) and decreased at 1 month (6.73, 6.27-7.12; P<0.001) and 1-year follow-up (6.37, 5.91-6.94; P<0.001). In univariate analysis, baseline 11-dehydro-TXB2 was higher in patients with MACEs (n=60; 7.73, 7.07-8.60) compared with those without MACEs (n=119; 7.28, 6.68-7.79; P=0.002). In multivariate regression model, 11-dehydro-TXB2 and 3 other variables (diabetes, multivessel disease, and left ventricular ejection fraction) were found to be best 1-year cumulative MACE predictors with odds ratio for 11-dehydro-TXB2 of 1.58 (95% CI 1.095-2.33; P=0.017) and area under the curve (in receiver operating characteristic analysis of 0.8). Baseline 11-dehydro-TXB2 negatively correlated with both left ventricular ejection fraction on admission (R=-0.21; P=0.006) and after 1 year (R=-0.346; P<0.001). CONCLUSIONS 11-Dehydro-TXB2 predicts 1-year cumulative MACEs in AMI patients and provides prognostic information on the left ventricular performance.
Collapse
Affiliation(s)
- Wojciech Szczeklik
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Edyta Stodółkiewicz
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Rzeszutko
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Tomala
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anton Chrustowicz
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Żmudka
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Sanak
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
48
|
Petrucci G, Rizzi A, Cavalca V, Habib A, Pitocco D, Veglia F, Ranalli P, Zaccardi F, Pagliaccia F, Tremoli E, Patrono C, Rocca B. Patient-independent variables affecting the assessment of aspirin responsiveness by serum thromboxane measurement. Thromb Haemost 2016; 116:891-896. [PMID: 27440714 DOI: 10.1160/th16-05-0349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 06/15/2016] [Indexed: 12/12/2022]
Abstract
The serum TXB2 (sTXB2) assay reflects the pharmacodynamics of platelet inhibition by low-dose aspirin. However, different studies reported variable sTXB2 values. sTXB2 assay requires whole blood incubation at 37 °C as a condition for optimal thrombin generation, arachidonic acid release and its metabolism by platelet cyclooxygenase-1 to form TXA2. Access to 37 °C incubation may be variably delayed, and different methods to quantitate sTXB2 may contribute to variable results between different Centers. We investigated whether delaying 37 °C incubation and/or analytical issues affect sTXB2 concentrations, biasing the assessment of aspirin responsiveness. Sixty-eight samples from 54 volunteers, on- and off-aspirin, were incubated at 37 °C immediately after sampling (reference sample) or after 5, 10, 15, 20, 30 or 60 minutes at room temperature (RT); 8 samples remained at RT 60 minutes, without subsequent incubation; 314 sera were measured by enzyme immunoassay (EIA) and liquid chromatography-tandem mass-spectrometry (LC/MS-MS) methods. sTXB2 concentrations decreased exponentially as a function of the delay before 37 °C incubation, ranging from 94 ± 11 % at 5 minutes to 23 ± 22 % of the reference sample after 60 minutes at RT. There was high agreement between EIA and LC/MS-MS. Moreover, we simulated the influence of a 15- or 30-minute delayed incubation on 300 sTXB2 measurements from previously-studied, aspirin-treated patients. Delayed incubation reduced the percentage of aspirin 'non-responders' by 22 % to 52 %, depending on the response threshold. In conclusion, a variable delay in the 37 °C incubation of blood samples may affect the assessment of platelet cyclooxygenase-1 inhibition by aspirin and confound the characterization of the determinants of aspirin responsiveness.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Bianca Rocca
- Bianca Rocca, MD, PhD, Istituto di Farmacologia, Università Cattolica, Largo F. Vito 1, 00168 Rome, Italy, Tel.: +39 06 30154253, E-mail: ;
| |
Collapse
|
49
|
|
50
|
Gori AM, Grifoni E, Valenti R, Giusti B, Paniccia R, Parodi G, Migliorini A, Antoniucci D, Abbate R, Gensini GF, Marcucci R. High on-aspirin platelet reactivity predicts cardiac death in acute coronary syndrome patients undergoing PCI. Eur J Intern Med 2016; 30:49-54. [PMID: 26764084 DOI: 10.1016/j.ejim.2015.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/03/2015] [Accepted: 12/11/2015] [Indexed: 01/15/2023]
Affiliation(s)
- Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Don Carlo Gnocchi Foundation, IRCCS, Florence, Italy
| | - Elisa Grifoni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | | | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Rita Paniccia
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | | | | | - Rosanna Abbate
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gian Franco Gensini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Don Carlo Gnocchi Foundation, IRCCS, Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| |
Collapse
|