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Narendren A, Whitehead N, Burrell LM, Yudi MB, Yeoh J, Jones N, Weinberg L, Miles LF, Lim HS, Clark DJ, Al-Fiadh A, Farouque O, Koshy AN. Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations. J Clin Med 2024; 13:4416. [PMID: 39124683 PMCID: PMC11312870 DOI: 10.3390/jcm13154416] [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: 06/10/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.
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Affiliation(s)
- Ahthavan Narendren
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
| | - Natalie Whitehead
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Louise M. Burrell
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Matias B. Yudi
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Nicholas Jones
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Han S. Lim
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - David J. Clark
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Anoop N. Koshy
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
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Marquis‐Gravel G, Stebbins A, Wruck LM, Roe MT, Effron MB, Hammill BG, Whittle J, VanWormer JJ, Robertson HR, Alikhaani JD, Kripalani S, Farrehi PM, Girotra S, Benziger CP, Polonsky TS, Merritt JG, Gupta K, McCormick TE, Knowlton KU, Jain SK, Kochar A, Rothman RL, Harrington RA, Hernandez AF, Jones WS. Age and Aspirin Dosing in Secondary Prevention of Atherosclerotic Cardiovascular Disease. J Am Heart Assoc 2024; 13:e026921. [PMID: 38348779 PMCID: PMC11010083 DOI: 10.1161/jaha.122.026921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/04/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND In patients with atherosclerotic cardiovascular disease, increasing age is concurrently associated with higher risks of ischemic and bleeding events. The objectives are to determine the impact of aspirin dose on clinical outcomes according to age in atherosclerotic cardiovascular disease. METHODS AND RESULTS In the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) trial, patients with atherosclerotic cardiovascular disease were randomized to daily aspirin doses of 81 mg or 325 mg. The primary effectiveness end point was death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke. The primary safety end point was hospitalization for bleeding requiring transfusion. A total of 15 076 participants were randomized to aspirin 81 mg (n=7540) or 325 mg (n=7536) daily (median follow-up: 26.2 months; interquartile range: 19.0-34.9 months). Median age was 67.6 years (interquartile range: 60.7-73.6 years). Among participants aged <65 years (n=5841 [38.7%]), a primary end point occurred in 226 (7.54%) in the 81 mg group, and in 191 (6.80%) in the 325 mg group (adjusted hazard ratio [HR], 1.23 [95% CI, 1.01-1.49]). Among participants aged ≥65 years (n=9235 [61.3%]), a primary end point occurred in 364 (7.12%) in the 81 mg group, and in 378 (7.96%) in the 325 mg group (adjusted HR, 0.95 [95% CI, 0.82-1.10]). The age-dose interaction was not significant (P=0.559). There was no significant interaction between age and the randomized aspirin dose for the secondary effectiveness and the primary safety bleeding end points (P>0.05 for all). CONCLUSIONS Age does not modify the impact of aspirin dosing (81 mg or 325 mg daily) on clinical end points in secondary prevention of atherosclerotic cardiovascular disease.
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Affiliation(s)
- Guillaume Marquis‐Gravel
- Duke Clinical Research InstituteDurhamNC
- Montreal Heart Institute, Université de MontréalQCCanada
| | | | | | - Matthew T. Roe
- Duke Clinical Research InstituteDurhamNC
- Duke University Medical CenterDurhamNC
| | - Mark B. Effron
- Ochsner Clinical School, John Ochsner Heart and Vascular Institute, University of Queensland School of MedicineNew OrleansLA
| | - Bradley G. Hammill
- Duke Clinical Research InstituteDurhamNC
- Department of Population Health SciencesDuke School of MedicineDurhamNC
| | - Jeff Whittle
- Department of Medicine, Division of General Internal MedicineMedical College of WisconsinMilwaukeeWI
- Center for Advancing Population Science, Medical College of WisconsinMilwaukeeWI
| | | | | | | | - Sunil Kripalani
- Vanderbilt Institute for Medicine and Public HealthVanderbilt University Medical CenterNashvilleTN
| | - Peter M. Farrehi
- Division of Cardiovascular MedicineUniversity of MichiganAnn ArborMI
| | - Saket Girotra
- University of Iowa Carver College of Medicine and Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical CenterIowa CityIA
| | | | | | - J. Greg Merritt
- Patient‐Centered Network of Learning Health Systems (LHSNet)Ann ArborMI
| | - Kamal Gupta
- University of Kansas Medical Center and HospitalKS
| | | | | | - Sandeep K. Jain
- University of Pittsburgh School of Medicine, UPMC Heart and Vascular InstitutePittsburghPA
| | | | - Russell L. Rothman
- Vanderbilt Institute for Medicine and Public HealthVanderbilt University Medical CenterNashvilleTN
| | | | - Adrian F. Hernandez
- Duke Clinical Research InstituteDurhamNC
- Duke University Medical CenterDurhamNC
| | - W. Schuyler Jones
- Duke Clinical Research InstituteDurhamNC
- Duke University Medical CenterDurhamNC
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Verdoia M, Nardin M, Gioscia R, Rognoni A, De Luca G. Antiplatelet Effect of Low-Dose Prasugrel in Elderly Patients Undergoing Percutaneous Coronary Interventions. Curr Vasc Pharmacol 2024; 22:335-341. [PMID: 38847250 DOI: 10.2174/0115701611280276240529105022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/23/2024] [Accepted: 04/30/2024] [Indexed: 10/03/2024]
Abstract
BACKGROUND Low-dose prasugrel (5 mg) has been proposed for patients with Acute Coronary Syndrome (ACS) and advanced age or low body weight. However, the routine use of dose-adjusted prasugrel in this high-risk subset of patients is still debated. AIM This study aimed to assess the prevalence and predictors of HRPR among elderly patients treated with low-dose (5 mg) prasugrel to evaluate the routine use of dose-adjusted prasugrel in this high-risk subset of patients. METHODS We included 59 elderly patients (≥75 years) treated with Dual Antiplatelet Therapy (DAPT: acetylsalicylic acid (ASA) 100-160 mg + prasugrel 5 mg) after Percutaneous Coronary Interventions (PCI) and undergoing platelet function assessment (by whole blood impedance aggregometry) 30-90 days post-discharge. RESULTS At a median follow-up of 43 days (interquartile range-IQR: 32-54), high-on treatment residual platelet reactivity (HRPR) occurred in 25 patients (42.4%), who displayed a greater body mass index (BMI) (p=0.02), lower levels of vitamin D (p=0.05) and were more frequently treated with nitrates (p=0.03). After multivariate analysis, BMI was the only independent predictor of prasugrel HRPR, and a BMI >26 was the best cut-off for predicting HRPR (adjusted Odds Ratio - OR=8.6, 95%CI: 2.2-33.9, p=0.002). CONCLUSION Among elderly patients receiving DAPT after PCI, HRPR is common with low-dose prasugrel. A greater BMI, especially for values ≥26, is the only independent predictor of HRPR with prasugrel 5 mg.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Italy
| | - Matteo Nardin
- Division of Internal Medicine, Spedali Civili di Brescia, Brescia, Italy
| | - Rocco Gioscia
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Italy
| | - Andrea Rognoni
- Division of Cardiology, Ospedale Degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Dipartimento di Medicina Clinica e Sperimentale, AOU Policlinico "G Martino", Università degli Studi di Messina, Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi- Sant'Ambrogio, Milan, Italy
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Fujisaki T, Kuno T, Iwagami M, Miyamoto Y, Takagi H, Deharo P, Cuisset T, Briasoulis A, Panaich S, Latib A, Kohsaka S. Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2023; 102:788-802. [PMID: 37675959 DOI: 10.1002/ccd.30811] [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] [Received: 06/17/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients. METHODS PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding. RESULTS Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y12 inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies. CONCLUSIONS Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
- Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | | | - Sidakpal Panaich
- Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Thalmann I, Preiss D, Schlackow I, Gray A, Mihaylova B. Quality of care for secondary cardiovascular disease prevention in 2009-2017: population-wide cohort study of antiplatelet therapy use in Scotland. BMJ Qual Saf 2023:bmjqs-2023-016520. [PMID: 37775268 PMCID: PMC7616486 DOI: 10.1136/bmjqs-2023-016520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Antiplatelet therapy (APT) can substantially reduce the risk of further vascular events in individuals with established atherosclerotic cardiovascular disease (ASCVD). However, knowledge regarding the extent and determinants of APT use is limited. OBJECTIVES Estimate the extent and identify patient groups at risk of suboptimal APT use at different stages of the treatment pathway. METHODS Retrospective cohort study using linked NHS Scotland administrative data of all adults hospitalised for an acute ASCVD event (n=150 728) from 2009 to 2017. Proportions of patients initiating, adhering to, discontinuing and re-initiating APT were calculated overall and separately for myocardial infarction (MI), ischaemic stroke and peripheral arterial disease (PAD). Multivariable logistic regression and Cox proportional hazards models were used to assess the contribution of patient characteristics in initiating and discontinuing APT. RESULTS Of patients hospitalised with ASCVD, 84% initiated APT: 94% following an MI, 83% following an ischaemic stroke and 68% following a PAD event. Characteristics associated with lower odds of initiation included female sex (22% less likely than men), age below 50 years or above 70 years (aged <50 years 26% less likely, and aged 70-79, 80-89 and ≥90 years 21%, 39% and 51% less likely, respectively, than those aged 60-69 years) and history of mental health-related hospitalisation (45% less likely). Of all APT-treated individuals, 22% discontinued treatment. Characteristics associated with discontinuation were similar to those related to non-initiation. CONCLUSIONS APT use remains suboptimal for the secondary prevention of ASCVD, particularly among women and older patients, and following ischaemic stroke and PAD hospitalisations.
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Affiliation(s)
- Inna Thalmann
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Preiss
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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6
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Kuno T, Watanabe A, Shoji S, Fujisaki T, Ueyama H, Takagi H, Deharo P, Cuisset T, Bangalore S, Mehran R, Stone GW, Kohsaka S, Bhatt DL. Short-Term DAPT and DAPT De-Escalation Strategies for Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. Circ Cardiovasc Interv 2023; 16:e013242. [PMID: 37609850 DOI: 10.1161/circinterventions.123.013242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/13/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Short-term (≤6 months) dual antiplatelet therapy (DAPT) and DAPT de-escalation become attractive for patients with acute coronary syndrome. METHODS A systemic search identified randomized controlled trials that included patients with acute coronary syndrome treated using (1) standard DAPT (12 months) with clopidogrel, prasugrel (standard/low dose), or ticagrelor; (2) extended DAPT (≥18 months); (3) short-term DAPT (≤6 months) followed by P2Y12 inhibitor or aspirin; (4) 12-month DAPT with unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitor or clopidogrel at 1 month; and (5) guided selection DAPT with genotype or platelet function tests. The primary efficacy outcome (major adverse cardiovascular events) was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. RESULTS This meta-analysis included 32 randomized controlled trials with 103 497 patients. While there were no differences in efficacy between short, unguided de-escalation and guided selection strategies, unguided de-escalation was associated with reduced risk of major adverse cardiovascular events compared with standard DAPT with clopidogrel or ticagrelor (hazard ratio [95% CI], 0.67 [0.49-0.93] and 0.68 [0.50-0.93]). Both short DAPT followed by P2Y12 inhibitor and unguided de-escalation were associated with reduced risks in safety compared with other strategies, including guided selection (hazard ratio [95% CI], 0.66 [0.47-0.93] and 0.48 [0.33-0.71]). Short DAPT followed by a P2Y12 inhibitor was associated with reduced risk of major bleeding and all-cause death compared with standard, extended DAPT (eg, versus DAPT with clopidogrel; hazard ratio [95% CI], 0.64 [0.42-0.97] and 0.60 [0.44-0.82]). By rankogram, unguided de-escalation strategy was the safest and most effective strategy in reducing major adverse cardiovascular events and major or minor bleeding while short DAPT followed by P2Y12 inhibitor was ranked the best for major bleeding and all-cause death. CONCLUSIONS In patients with acute coronary syndrome, unguided de-escalation was associated with the lowest risk of major adverse cardiovascular events and major or minor bleeding outcomes, while short DAPT followed by P2Y12 inhibitor was associated with the lowest risk of major bleeding and all-cause death.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center (T.K.), Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
- Division of Cardiology (T.K.), Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Atsuyuki Watanabe
- Department of Medicine, Mount Sinai Beth Israel (A.W.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
- Duke Clinical Research Institute, Durham, NC (S.S.)
| | - Tomohiro Fujisaki
- Department of Medicine, Mount Sinai Morningside and West (T.F.), Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.F.)
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (T.F.)
| | - Hiroki Ueyama
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (H.U.)
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Japan (H.T.)
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.)
- INSERM, INRA, C2VN (P.D., T.C.), Aix-Marseille Université, France
- Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.)
- INSERM, INRA, C2VN (P.D., T.C.), Aix-Marseille Université, France
- Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Sripal Bangalore
- Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine (S.B.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute (R.M., G.W.S.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute (R.M., G.W.S.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY (D.L.B.)
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7
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De Servi S, Landi A, Savonitto S, Morici N, De Luca L, Montalto C, Crimi G, De Rosa R, De Luca G. Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field. J Clin Med 2023; 12:2082. [PMID: 36902869 PMCID: PMC10003933 DOI: 10.3390/jcm12052082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/23/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, 27100 Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland
| | | | - Nuccia Morici
- IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy
| | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, 00152 Roma, Italy
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
- Clinical and Interventional Cardiology, Istituto Clinico Sant’Ambrogio, Gruppo San Donato, 20122 Milan, Italy
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS, Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Roberta De Rosa
- University Hospital San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
- Goethe University Hospital Frankfurt, 60528 Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98039 Messina, Italy
- Division of Cardiology, Nuovo Galeazzi-Sant’Ambrogio Hospital, 20161 Milan, Italy
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8
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Andreotti F, Geisler T, Collet JP, Gigante B, Gorog DA, Halvorsen S, Lip GYH, Morais J, Navarese EP, Patrono C, Rocca B, Rubboli A, Sibbing D, Storey RF, Verheugt FWA, Vilahur G. Acute, periprocedural and longterm antithrombotic therapy in older adults: 2022 Update by the ESC Working Group on Thrombosis. Eur Heart J 2023; 44:262-279. [PMID: 36477865 DOI: 10.1093/eurheartj/ehac515] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 07/22/2022] [Accepted: 09/07/2022] [Indexed: 12/12/2022] Open
Abstract
The first international guidance on antithrombotic therapy in the elderly came from the European Society of Cardiology Working Group on Thrombosis in 2015. This same group has updated its previous report on antiplatelet and anticoagulant drugs for older patients with acute or chronic coronary syndromes, atrial fibrillation, or undergoing surgery or procedures typical of the elderly (transcatheter aortic valve implantation and left atrial appendage closure). The aim is to provide a succinct but comprehensive tool for readers to understand the bases of antithrombotic therapy in older patients, despite the complexities of comorbidities, comedications and uncertain ischaemic- vs. bleeding-risk balance. Fourteen updated consensus statements integrate recent trial data and other evidence, with a focus on high bleeding risk. Guideline recommendations, when present, are highlighted, as well as gaps in evidence. Key consensus points include efforts to improve medical adherence through deprescribing and polypill use; adoption of universal risk definitions for bleeding, myocardial infarction, stroke and cause-specific death; multiple bleeding-avoidance strategies, ranging from gastroprotection with aspirin use to selection of antithrombotic-drug composition, dosing and duration tailored to multiple variables (setting, history, overall risk, age, weight, renal function, comedications, procedures) that need special consideration when managing older adults.
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Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Largo F Vito 1, 00168 Rome, Italy.,Department of Cardiovascular and Pneumological Sciences, Catholic University, Rome, Italy
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Otfried-Müller-Straße 10, 72076 Tuebingen, Germany
| | - Jean-Philippe Collet
- Paris Sorbonne Université (UPMC), ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Joao Morais
- Serviço de Cardiologia, Centro Hospitalar de Leiria and Center for Innovative Care and Health Technology (ciTechCare), Leiria Polytechnic Institute, Leiria, Portugal
| | - Eliano Pio Navarese
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,SIRIO MEDICINE Network and Faculty of Medicine University of Alberta, Edmonton, Canada
| | - Carlo Patrono
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Seeshaupt, Germany & Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Program-ICCC, Research Institute-Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV, Instituto Salud Carlos III, Madrid, Spain
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9
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De Luca G, Verdoia M, Morici N, Ferri LA, Piatti L, Grosseto D, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Ferrario M, Murena E, Tondi S, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Antonicelli R, Cesana BM, De Luca L, Ottani F, Moffa N, Savonitto S, De Servi S. Impact of hemoglobin levels at admission on outcomes among elderly patients with acute coronary syndrome treated with low-dose Prasugrel or clopidogrel: A sub-study of the ELDERLY ACS 2 trial. Int J Cardiol 2022; 369:5-11. [PMID: 35907504 DOI: 10.1016/j.ijcard.2022.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/15/2022]
Abstract
Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk. METHODS All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission. RESULTS We included in our analysis 1364 patients, divided in quartiles of Hb values (<12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR[95%CI] = 0.76 [0.59-0.97], p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR[95%CI] = 1.22 [0.41-3.6], p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients. CONCLUSIONS Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.
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Affiliation(s)
- Giuseppe De Luca
- Clinical and Experimental Cardiology Unit, Azienda Ospedaliera-Universitaria "Sassari", University of Sassari, Sassari, Italy.
| | - Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, Biella, Italy
| | - Nuccia Morici
- IRCCSS. Maria Nascente Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | | | | | | | - Irene Bossi
- IRCCSS. Maria Nascente Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | | | | | | | | | | | | | | | | | | | - Elena Corrada
- Humanitas Clinical and Research Center, Rozzano, Italy
| | | | | | | | | | | | | | - Bruno M Cesana
- Statistics and Biomathematics Unit, Department of Molecular and Transactional Medicine, University of Brescia, Brescia, Italy
| | - Leonardo De Luca
- Department of Cardiosciences, AO San Camillo-Forlanini, Roma, Italy
| | | | | | | | - Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, Pavia, Italy
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10
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Farag M, Jeyalan V, Ferreiro JL, Jeong YH, Geisler T, Gorog DA. Reduction or de-escalation of dual antiplatelet therapy intensity or duration in patients with acute coronary syndromes undergoing percutaneous coronary intervention: A mini-review. Front Cardiovasc Med 2022; 9:1018649. [PMID: 36337887 PMCID: PMC9630649 DOI: 10.3389/fcvm.2022.1018649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/30/2022] [Indexed: 11/15/2022] Open
Abstract
Current guidelines for patients with acute coronary syndrome (ACS) recommend dual antiplatelet therapy (DAPT) for 12 months. Since bleeding is the main Achilles' heel of DAPT, in recent years several randomized controlled trials have evaluated the safety and efficacy of de-escalation of DAPT with respect to ischaemic and bleeding endpoints. These trials can be broadly divided into studies evaluating a shorter duration of DAPT, and those studies in which DAPT that includes a potent P2Y12 inhibitor, such as prasugrel or ticagrelor, is compared to less intense DAPT, mainly clopidogrel or reduced-dose prasugrel. We sought to evaluate the studies assessing de-escalation of DAPT in patients with ACS undergoing PCI. We review the studies evaluating the strategies of de-escalation of DAPT intensity and those evaluating a strategy of de-escalation of DAPT duration in ACS patients undergoing PCI. We summarize the limitations of studies to date, gaps in evidence and make recommendations for future studies.
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Affiliation(s)
- Mohamed Farag
- Department of Cardiology, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
- Department of Clinical, Pharmaceutical and Biological Science, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
- *Correspondence: Mohamed Farag
| | - Visvesh Jeyalan
- Department of Cardiothoracic, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Jose Luis Ferreiro
- Department of Cardiology, CIBERCV, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, South Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tübingen, Germany
| | - Diana A. Gorog
- Department of Cardiology, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom
- Department of Clinical, Pharmaceutical and Biological Science, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
- Imperial College, National Heart and Lung Institute, London, United Kingdom
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11
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Dual Antiplatelet Therapy in Patients Aged 75 Years and Older with Coronary Artery Disease: A Meta-Analysis and Systematic Review. J Interv Cardiol 2022; 2022:3111840. [PMID: 36176329 PMCID: PMC9499790 DOI: 10.1155/2022/3111840] [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: 04/22/2022] [Revised: 07/31/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives This systematic review and meta-analysis evaluates the safety and efficacy of dual antiplatelet therapy (DAPT) in elderly patients with acute coronary syndrome (ACS). Background The safety and efficacy of DAPT in elderly patients with ACS is not well characterized. Methods We performed a systematic literature review to identify clinical studies that reported safety and efficacy outcomes after DAPT for ACS in elderly patients. The primary outcomes of primary efficacy endpoint rates and bleeding event rates were reported as random effects risk ratio (RR) with 95% confidence interval. No prior ethical approval was required since all data are public. Results Our search yielded 660 potential studies. We included 8 studies reporting on 29,217 patients. There was a higher risk of bleeding event rates in elderly patients treated with prasugrel or ticagrelor when compared to clopidogrel with a risk ratio of 1.17 (95% CI 1.08 to 1.27, p < 0.05). There was no difference in primary efficacy endpoint rates between elderly patients treated with prasugrel or ticagrelor when compared to clopidogrel with a risk ratio of 0.85 (95% CI 0.68 to 1.07, p=0.17). Conclusions This systematic review and meta-analysis suggests that DAPT with prasugrel or ticagrelor compared to clopidogrel is associated with a higher risk of bleeding events in elderly patients with ACS. There was no difference in the primary efficacy endpoints between the two treatment groups.
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12
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Modulation of Glycoprotein VI and Its Downstream Signaling Pathways as an Antiplatelet Target. Int J Mol Sci 2022; 23:ijms23179882. [PMID: 36077280 PMCID: PMC9456422 DOI: 10.3390/ijms23179882] [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: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Antiplatelet therapy aims to reduce the risk of thrombotic events while maintaining hemostasis. A promising current approach is the inhibition of platelet glycoprotein GPVI-mediated adhesion pathways; pathways that do not involve coagulation. GPVI is a signaling receptor integral for collagen-induced platelet activation and participates in the thrombus consolidation process, being a suitable target for thrombosis prevention. Considering this, the blocking or antibody-mediated depletion of GPVI is a promising antiplatelet therapy for the effective and safe treatment of thrombotic diseases without a significant risk of bleeding and impaired hemostatic plug formation. This review describes the current knowledge concerning pharmaceutical approaches to platelet GPVI modulation and its downstream signaling pathways in this context.
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13
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Kuno T, Fujisaki T, Shoji S, Sahashi Y, Tsugawa Y, Iwagami M, Takagi H, Briasoulis A, Deharo P, Cuisset T, Latib A, Kohsaka S, Bhatt DL. Comparison of Unguided De-Escalation Versus Guided Selection of Dual Antiplatelet Therapy After Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis. Circ Cardiovasc Interv 2022; 15:e011990. [PMID: 35899618 DOI: 10.1161/circinterventions.122.011990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The benefit of dual antiplatelet therapy (DAPT) for reducing ischemic events is greatest in the early period of acute coronary syndrome, and recent randomized controlled trials have investigated the unguided de-escalation strategy of changing potent P2Y12 inhibitors to less potent or reduced-dose P2Y12 inhibitors 1 month after acute coronary syndrome. However, it remains unclear which strategy is more effective and safer: the uniform unguided de-escalation strategy versus the personalized guided selection of DAPT with genotype or platelet function tests. METHODS PubMed, EMBASE, and Cochrane Central were searched for articles published from database inception to September 10, 2021. Randomized controlled trials investigating DAPT using clopidogrel, low-dose prasugrel, standard-dose prasugrel, ticagrelor, unguided de-escalation strategy, and guided selection strategy for patients with acute coronary syndrome were included. Hazard ratios and relative risk estimates were extracted from each study. The estimates were pooled using a random-effects network meta-analysis. The primary efficacy outcome was major adverse cardiovascular events, defined as a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. Secondary outcomes were all-cause death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and major bleeding. RESULTS This study included 19 randomized controlled trials with 69 746 patients. Compared with guided selection of DAPT, unguided de-escalation of DAPT was associated with a decreased risk of the primary safety outcome (hazard ratio, 0.48 [95% CI, 0.33-0.72]) without increased risks of major adverse cardiovascular events (hazard ratio, 0.82 [95% CI, 0.53-1.28]) or any secondary outcomes. The results were similar when the guided selection strategy was divided into platelet function-guided and genotype-guided strategies. CONCLUSIONS Compared with guided selection of DAPT, unguided de-escalation of DAPT decreased bleeding without increasing ischemic events in patients after acute coronary syndrome. If a strategy of de-escalation is chosen, these findings do not support the routine use of personalized guiding tests. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021273082.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY (T.K., A.L.).,Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY (T.K.)
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.F.).,Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY (T.F.)
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
| | - Yuki Sahashi
- Department of Cardiology, Gifu University, Japan (Y.S.)
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA (Y.T.).,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA (Y.T.)
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Japan (M.I.)
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Japan (H.T.)
| | - Alexandros Briasoulis
- Division of Cardiology, Heart Failure and Transplantation, University of Iowa' Iowa City (A.B.)
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.).,Center for Cardiovascular and Nutrition Research, INSERM, INRA (P.D., T.C.), Aix-Marseille Université, France.,Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.).,Center for Cardiovascular and Nutrition Research, INSERM, INRA (P.D., T.C.), Aix-Marseille Université, France.,Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY (T.K., A.L.)
| | - Shun Kohsaka
- Department of Cardiology, Gifu University, Japan (Y.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
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14
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Passacquale G, Sharma P, Perera D, Ferro A. Antiplatelet therapy in cardiovascular disease: Current status and future directions. Br J Clin Pharmacol 2022; 88:2686-2699. [PMID: 35001413 PMCID: PMC9303765 DOI: 10.1111/bcp.15221] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Antiplatelet medications remain a cornerstone of therapy for atherosclerotic cardiovascular and cerebrovascular diseases. In primary prevention (patients with cardiovascular risk factors but no documented events, symptoms or angiographic disease), there is little evidence of benefit of any antiplatelet therapy, and such therapy carries the risk of excess bleeding. Where there is documented disease (secondary prevention), stable patients benefit from long-term antiplatelet monotherapy, aspirin being first choice in those with coronary heart disease and clopidogrel in those with cerebrovascular disease; moreover, recent evidence shows that low-dose rivaroxaban in combination with aspirin confers added benefit, in patients with stable cardiovascular and peripheral arterial disease. In patients with acute cerebrovascular disease, aspirin combined with clopidogrel reduces subsequent risk, while in acute coronary syndrome, dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) confers greater protection than aspirin monotherapy, with prasugrel and ticagrelor offering greater antiplatelet efficacy with faster onset of action than clopidogrel. Although greater antiplatelet efficacy is advantageous in preventing thrombotic events, this must be tempered by increased risk of bleeding, which may be a particular issue in certain patient groups, as will be discussed. We will also discuss possible future approaches to personalisation of antiplatelet therapy.
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Affiliation(s)
- Gabriella Passacquale
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research ExcellenceKing's College LondonLondonUK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal HollowayUniversity of LondonEghamSurreyUK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research ExcellenceKing's College LondonLondonUK
| | - Albert Ferro
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research ExcellenceKing's College LondonLondonUK
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15
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Regulation of Key Antiplatelet Pathways by Bioactive Compounds with Minimal Bleeding Risk. Int J Mol Sci 2021; 22:ijms222212380. [PMID: 34830261 PMCID: PMC8620148 DOI: 10.3390/ijms222212380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/04/2023] Open
Abstract
Cardiovascular disease is strongly influenced by platelet activation. Platelet activation and thrombus formation at atherosclerotic plaque rupture sites is a dynamic process regulated by different signaling networks. Therefore, there are now focused efforts to search for novel bioactive compounds which target receptors and pathways in the platelet activation process while preserving normal hemostatic function. The antiplatelet activity of numerous fruits and vegetables and their multiple mechanisms of action have recently been highlighted. In this review, we review the antiplatelet actions of bioactive compounds via key pathways (protein disulfide isomerase, mitogen-activated protein kinases, mitochondrial function, cyclic adenosine monophosphate, Akt, and shear stress-induced platelet aggregation) with no effects on bleeding time. Therefore, targeting these pathways might lead to the development of effective antiplatelet strategies that do not increase the risk of bleeding.
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16
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The influence of acute coronary syndrome on levels of clopidogrel active metabolite and platelet inhibition in patients with and without CYP2C19*2(681 G>A), *3(636 G>A) and ABCB1(C3435C> T) gene polymorphisms. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:179-186. [PMID: 34400920 PMCID: PMC8356835 DOI: 10.5114/aic.2021.106894] [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: 02/26/2021] [Accepted: 04/20/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Although ticagrelor and prasugrel remain the standard antiplatelet treatments in acute coronary syndrome (ACS), numerous patients still present with indications for clopidogrel use. Aim We aimed to assess the levels of clopidogrel active metabolite and to evaluate the effect of the drug on platelet inhibition in patients with ACS as compared with those with stable coronary disease. Patients were assessed for the presence of the most common genetic polymorphisms that reduce the absorption (ABCB1) and activation (CYP2C19*2 and CYP2C19*3) of clopidogrel to exclude the effect of genetic variability on drug concentrations and activity. Material and methods This single-center, open-label, prospective study included 199 patients hospitalized due to ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) in Killip class I–III, who underwent percutaneous coronary intervention. The control group included 22 patients with stable coronary artery disease. Results The mean (SD) levels of active clopidogrel were 17.1 (12.3) ng/ml in controls and 16.4 (12.0) ng/ml in the whole study group (p < 0.68). No differences were noted in clopidogrel levels between patients with STEMI and NSTEMI (mean (SD), 17.6 (2.3) ng/ml and 15.1 (11.5) ng/ml; p < 0.45) or between STEMI and NSTEMI groups and controls (p < 0.38 and p < 0.61, respectively). No effect of ABCB1 or CYP2C19 polymorphism was observed in the study subgroups. Conclusions We concluded that ACS does not affect the levels of clopidogrel active metabolite or platelet inhibition in patients in Killip class I-III with or without CYP2C19 or ABCB1 gene polymorphisms.
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17
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Abusnina W, Al-Abdouh A, Bizanti A, Gill G, Houssien A, Alshebani Y, Kanmanthareddy A, Dahal K. Ischemic and bleeding outcomes of potent P2Y12 inhibitor antiplatelet agents versus clopidogrel in elderly patients with acute coronary syndrome: A meta-analysis of randomized trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 38:54-60. [PMID: 34384690 DOI: 10.1016/j.carrev.2021.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population. METHODS AND RESULTS PubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82-1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75-1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78-1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82-1.86]; p=0.31). However, potent oral P2Y12 inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68-0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09-1.59]; p<0.01). CONCLUSION In comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Ahmad Al-Abdouh
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD 21229, USA
| | - Anas Bizanti
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD 21229, USA
| | - Gauravpal Gill
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Abdelrazeg Houssien
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Yazeid Alshebani
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Arun Kanmanthareddy
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Khagendra Dahal
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA.
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18
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Morici N, De Servi S, De Luca L, Crimi G, Montalto C, De Rosa R, De Luca G, Rubboli A, Valgimigli M, Savonitto S. Management of acute coronary syndromes in older adults. Eur Heart J 2021; 43:1542-1553. [PMID: 34347065 DOI: 10.1093/eurheartj/ehab391] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/03/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit-risk ratio compared to a conservative one across the ACS spectrum, even considering patients' clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.
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Affiliation(s)
- Nuccia Morici
- Unità di Cure Intensive Cardiologiche, and De Gasperis Cardio-Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | | | - Leonardo De Luca
- Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Gabriele Crimi
- Cardio Thoraco Vascular Department (DICATOV), Interventional Cardiology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | | | - Roberta De Rosa
- Department of Cardiology, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU Maggiore della Carità, Università del Piemonte Orientale, Novara, Italy
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Disease-AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
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19
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Shoji S, Kuno T, Fujisaki T, Takagi H, Briasoulis A, Deharo P, Cuisset T, Latib A, Kohsaka S. De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2021; 78:763-777. [PMID: 34275697 DOI: 10.1016/j.jacc.2021.06.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent P2Y12 inhibitors has become a cornerstone of acute coronary syndrome (ACS) management. Recent randomized controlled trials (RCTs) have investigated DAPT de-escalation to decrease the risk of bleeding outcomes. OBJECTIVES The aim of this study was to compare the efficacy and safety outcomes of various DAPT strategies in patients with ACS, including de-escalation from a potent P2Y12 inhibitor to clopidogrel or low-dose prasugrel. METHODS MEDLINE and EMBASE were searched through January 2021 for RCTs investigating the efficacy and safety of DAPT in patients with ACS, and a network meta-analysis was conducted. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding. RESULTS Our search identified 15 eligible RCTs, including 55,798 patients with ACS. De-escalation therapy was associated with reduced risk of primary bleeding outcomes (HR: 0.48 [95% CI: 0.30-0.77] vs clopidogrel; HR: 0.32 [95% CI: 0.20-0.52] vs ticagrelor; HR: 0.36 [95% CI: 0.24-0.55] vs standard-dose prasugrel; and HR: 0.40 [95% CI: 0.22-0.75] vs low-dose prasugrel) without negatively affecting primary efficacy outcomes. There were no significant differences in ischemic or bleeding outcomes between de-escalation to clopidogrel or low-dose prasugrel. CONCLUSIONS Compared with other established uses of DAPT, de-escalation was the most effective strategy for ACS treatment, resulting in fewer bleeding events without increasing ischemic events.
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Affiliation(s)
- Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan. https://twitter.com/satoshishoji2
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA.
| | - Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, New York, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Alexandros Briasoulis
- Division of Cardiology, Heart Failure and Transplantation, University of Iowa, Iowa City, Iowa, USA
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France; Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France; Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, New York, New York, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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20
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Angiolillo DJ, Cao D, Baber U, Sartori S, Zhang Z, Dangas G, Mehta S, Briguori C, Cohen DJ, Collier T, Dudek D, Escaned J, Gibson CM, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Moliterno DJ, Ohman EM, Oldroyd K, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Impact of Age on the Safety and Efficacy of Ticagrelor Monotherapy in Patients Undergoing PCI. JACC Cardiovasc Interv 2021; 14:1434-1446. [PMID: 34238553 DOI: 10.1016/j.jcin.2021.04.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The aim of this study was to assess the impact of age on the safety and efficacy of ticagrelor monotherapy after percutaneous coronary intervention (PCI). BACKGROUND As the risk for bleeding and ischemic complications after PCI increases with age, the authors conducted a pre-specified analysis of the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial to evaluate the possible benefits of ticagrelor monotherapy according to age. METHODS The TWILIGHT trial enrolled patients undergoing PCI with drug-eluting stents who fulfilled at least 1 clinical and 1 angiographic high-risk criterion. Age ≥65 years was a clinical entry criterion. After 3 months of dual-antiplatelet therapy with ticagrelor, event-free patients were randomized to ticagrelor plus placebo or ticagrelor plus aspirin for an additional 12 months. The primary endpoint was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction, or stroke. RESULTS A total of 3,113 patients (47.7%) were ≥65 years of age. At 1 year after randomization, ticagrelor monotherapy significantly reduced BARC type 2, 3, or 5 bleeding (4.5% vs. 8.2%; hazard ratio: 0.53; 95% confidence interval: 0.40 to 0.71) without increasing ischemic events (4.2% vs. 4.4%; hazard ratio: 0.96; 95% confidence interval: 0.68 to 1.35) compared with ticagrelor plus aspirin among patients ≥65 years of age. These findings were consistent in patients <65 years of age with respect to the primary (pinteraction = 0.62) and key secondary (pinteraction = 0.77) endpoints and across different age categories. CONCLUSIONS A strategy of ticagrelor monotherapy following 3 months of dual-antiplatelet therapy significantly reduced clinically relevant bleeding compared with ticagrelor plus aspirin without an increase in ischemic events, irrespective of age.
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Affiliation(s)
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Usman Baber
- The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - David J Cohen
- University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Timothy Collier
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Keith Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | | | - Giora Weisz
- NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, USA
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA.
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21
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Fujisaki T, Kuno T, Ando T, Briasoulis A, Takagi H, Bangalore S. Potent P2Y12 inhibitors versus Clopidogrel in elderly patients with acute coronary syndrome: Systematic review and meta-analysis. Am Heart J 2021; 237:34-44. [PMID: 33737060 DOI: 10.1016/j.ahj.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/09/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known. OBJECTIVES To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS. METHODS PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE). RESULTS Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P = .31, I2 = 9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P = .22, I2 = 29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P = .03, I2 = 16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P = .02, I2 = 0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel. CONCLUSIONS Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside and West, New York, NY
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY.
| | - Tomo Ando
- Department of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NY
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22
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Roule V, Lemaitre A, Pommier W, Bignon M, Sabatier R, Blanchart K, Beygui F. Safety and efficacy of very short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy in older patients undergoing percutaneous coronary intervention: meta-analysis of randomised controlled trials. Age Ageing 2021; 50:1102-1107. [PMID: 33755049 DOI: 10.1093/ageing/afab047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND older patients undergoing percutaneous coronary intervention (PCI) represent a growing population sharing both a high ischemic and bleeding risk. Dual antiplatelet therapy (DAPT) reduces the incidence of thrombotic events but exposes patients to an increased risk of bleeding and subsequent mortality. Its optimal duration after PCI remains unclear. OBJECTIVE to assess the impact of short-duration DAPT on both bleeding and ischemic events in the specific population of older patients undergoing PCI. METHODS we performed a meta-analysis of randomised controlled trials comparing the safety and efficacy of standard versus very short duration (≤ 3 months, followed by P2Y12 inhibitor monotherapy) DAPT after PCI with a drug-eluting stent in older patients. RESULTS four studies, representing 8,961 older patients, were finally included. Compared with standard duration, short-duration DAPT was associated with similar rates of major bleeding (relative risks, RR 0.70 [0.47; 1.05]) and the composite efficacy endpoint (RR 0.85 [0.63; 1.14]). There was a high level of heterogeneity between the studies (I2 = 68%) regarding major bleeding. CONCLUSION our meta-analysis suggests that short DAPT may be a valid option in older patients after PCI but it also highlights the need for specific studies in such patients on optimal duration of antiplatelet therapy.
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Affiliation(s)
- Vincent Roule
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000 Caen, France
| | - Adrien Lemaitre
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
| | - Wilhelm Pommier
- CHU de Caen Normandie, Service de Gériatrie, 14000 Caen, France
| | - Mathieu Bignon
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
| | - Rémi Sabatier
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
| | | | - Farzin Beygui
- CHU de Caen Normandie, Service de Cardiologie, 14000 Caen, France
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, 14000 Caen, France
- ACTION Academic Group, Pitié Salpêtrière University Hospital, 75013, Paris, France
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23
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Wongsalap Y, Ungsriwong S, Kumtep W, Saokaew S, Senthong V, Kengkla K. Efficacy and Safety of Low-Dose Prasugrel Versus Clopidogrel in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2021; 36:991-1000. [PMID: 34169380 DOI: 10.1007/s10557-021-07202-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To assess the efficacy and safety of low-dose prasugrel compared to clopidogrel based on the occurrence of major adverse cardiac events (MACEs) and major bleeding in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). METHODS The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were systematically searched up to May 2020 to identify relevant randomized controlled trials (RCTs) and observational studies. A meta-analysis was conducted using a random effects model to estimate relative risks (RRs) with 95% confidence intervals (CIs). The primary efficacy and safety endpoints were MACE and major bleeding, respectively. RESULTS Three RCTs (n = 2884) and five observational studies (n = 30,117) were included. A meta-analysis of RCTs revealed no significant differences in terms of MACE (RR 0.92, 95% CI 0.74 to 1.16) or major bleeding (RR 0.97, 95% CI 0.57 to 1.65) between low-dose prasugrel and clopidogrel. A meta-analysis of observational studies revealed no significant difference in terms of MACE (RR 1.13, 95% CI 0.82 to 1.55) between the two groups, but low-dose prasugrel was associated with a significantly increased risk of major bleeding (RR 1.33, 95% CI 1.02 to 1.72). CONCLUSIONS We found that low-dose prasugrel was not associated with changes in MACE or major bleeding compared with clopidogrel in RCTs. However, analysis of data from observational studies revealed that low-dose prasugrel was associated with an increased risk of major bleeding compared with clopidogrel.
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Affiliation(s)
- Yuttana Wongsalap
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand.,Unit of Excellence On Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | | | - Wanalee Kumtep
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Surasak Saokaew
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand.,Unit of Excellence On Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.,Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Selangor Darul Ehsan, Bandar Sunway, Malaysia.,Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor DarulEhsan, Bandar Sunway, Malaysia
| | - Vichai Senthong
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kirati Kengkla
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand. .,Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand. .,Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, 56000, Thailand. .,Unit of Excellence On Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand.
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24
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Tkacheva ON, Vorobyeva NM, Kotovskaya YV, Runikhina NK, Strazhesco ID, Villevalde SV, Drapkina OM, Komarov AL, Orlova YA, Panchenko EP, Pogosova NV, Frolova EV, Yavelov IS. Antithrombotic therapy in the elderly and senile age: the consensus opinion of experts of the Russian Association of Gerontologists and Geriatricians and the National Society of Preventive Cardiology. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
В данном документе обсуждаются особенности АТТ у лиц пожилого и старческого возраста в различных клинических ситуациях.
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25
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Kamran H, Jneid H, Kayani WT, Virani SS, Levine GN, Nambi V, Khalid U. Oral Antiplatelet Therapy After Acute Coronary Syndrome: A Review. JAMA 2021; 325:1545-1555. [PMID: 33877270 DOI: 10.1001/jama.2021.0716] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Acute coronary syndrome (ACS) is a major cause of morbidity and mortality in the United States with an annual incidence of approximately 1 million. Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces cardiovascular event rates after ACS. OBSERVATIONS In 2016, the updated guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommended aspirin plus a P2Y12 inhibitor for at least 12 months for patients with ACS. Since these recommendations were published, new randomized clinical trials have studied different regimens and durations of antiplatelet therapy. Recommendations vary according to the risk of bleeding. If bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established. If bleeding risk is high, shorter duration (ie, 3-6 months) of DAPT may be reasonable. A high risk of bleeding traditionally is defined as a 1-year risk of serious bleeding (either fatal or associated with a ≥3-g/dL drop in hemoglobin) of at least 4% or a risk of an intracranial hemorrhage of at least 1%. Patients at higher risk are 65 years old or older; have low body weight (BMI <18.5), diabetes, or prior bleeding; or take oral anticoagulants. The newest P2Y12 inhibitors, prasugrel and ticagrelor, are more potent, with high on-treatment residual platelet reactivity of about 3% vs 30% to 40% with clopidogrel and act within 30 minutes compared with 2 hours for clopidogrel. Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack because of an increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel, P = .002) and should avoid prescribing it to patients older than 75 years or who weigh less than 60 kg. The ISAR-REACT-5 trial found that prasugrel reduced rates of death, myocardial infarction, or stroke at 1 year compared with ticagrelor among patients with ACS undergoing percutaneous coronary intervention (9.3% vs 6.9%, P = .006) with no significant difference in bleeding. Recent trials suggested that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes. CONCLUSIONS AND RELEVANCE Dual antiplatelet therapy reduces rates of cardiovascular events in patients with acute coronary syndrome. Specific combinations and duration of dual antiplatelet therapy should be based on patient characteristics-risk of bleeding myocardial ischemia.
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Affiliation(s)
- Hassan Kamran
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Waleed T Kayani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Glenn N Levine
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Vijay Nambi
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Umair Khalid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
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Xu H, Bonaca MP, Goodrich E, Scirica BM, Morrow DA. Efficacy and safety of vorapaxar for secondary prevention in low body weight in patients with atherosclerosis: analyses from the TRA 2°P-TIMI 50 Trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:190–199. [PMID: 31642690 DOI: 10.1177/2048872619883354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/28/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vorapaxar inhibits the thrombin-mediated activation of platelets, reduces thrombotic events in patients with myocardial infarction or peripheral arterial disease while increasing bleeding. In the TRA 2°P-TIMI 50 trial, we observed a nominally significant interaction between low body weight and the reduced efficacy of vorapaxar. METHODS We investigated the relationship between body weight and the efficacy and safety of vorapaxar within a multinational, randomized, double-blind, placebo-controlled trial of vorapaxar in patients with atherosclerosis. This analysis was performed among 20,138 patients with a clinical indication for vorapaxar. RESULTS Compared with patients weighing 60 kg or more, patients weighing less than 60 kg were older, more frequently women, Asian and had renal insufficiency (each P<0.001). The efficacy of vorapaxar with respect to cardiovascular death, myocardial infarction and stroke showed a significant interaction with patients' weight (Pinteraction<0.03). However among patients younger than 65 years, vorapaxar reduced the primary endpoint regardless of weight (weight ≥60 kg: 6.4% vs. 8.1%, hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.65-0.86; weight <60 kg: 5.4% vs. 7.2%, HR 0.75, 95% CI 0.37-1.49, Pinteraction=0.98). Among patients aged 65 years and older, the efficacy of vorapaxar diminished in patients weighing less than 60 kg (high weight: 10.4% vs. 12.6%, HR 0.81, 95% CI 0.69-0.95; low weight: 16.1% vs. 9.0%, HR 1.62, 95% CI 0.95-2.76, Pinteraction=0.01). The relative increase in bleeding with vorapaxar was not modified by weight (all Pinteraction>0.05). CONCLUSIONS Vorapaxar reduced vascular events and improved net clinical outcome regardless of body weight in younger patients. Elderly patients with low weight may not be good candidates for aggressive secondary prevention with vorapaxar added to standard therapy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov Unique identifier: NCT00526474.
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Affiliation(s)
- Haiyan Xu
- TIMI Study Group, Brigham and Women's Hospital, USA
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Capranzano P, Angiolillo DJ. Antithrombotic Management of Elderly Patients With Coronary Artery Disease. JACC Cardiovasc Interv 2021; 14:723-738. [PMID: 33826494 DOI: 10.1016/j.jcin.2021.01.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/13/2023]
Abstract
Antithrombotic therapy represents the mainstay of treatment in patients with coronary artery disease (CAD), including elderly patients who are at increased risk for ischemic recurrences. However, the elderly population is also more vulnerable to bleeding complications. Numerous mechanisms, including abnormalities in the vasculature, thrombogenicity, comorbidities, and altered drug response, contribute to both increased thrombotic and bleeding risk. Age-related organ changes and drug-drug interactions secondary to polypharmacy lead to distinct pharmacokinetic and pharmacodynamic profiles of antithrombotic drugs. Overall these factors contribute to the risk-benefit profiles of antithrombotic therapies in elderly subjects and underscore the need for treatment regimens that can reduce bleeding while preserving efficacy. Given that the prevalence of CAD, as well as concomitant diseases with thromboembolic potential, such as atrial fibrillation, increases with age and that the elderly population is in continuous growth, understanding the safety and efficacy of different antithrombotic regimens is pivotal for patient-centered care. In the present overview the authors appraise the available data on the use of antithrombotic therapy in older patients with CAD to assist with the management of this high-risk population and define knowledge gaps that can set the basis for future research.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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Santos RCO, Bensenor IM, Goulart AC, Lotufo PA, Santos IS. Frequency and Reasons for Non-Administration and Suspension of Drugs During an Acute Coronary Syndrome Event. The ERICO Study. Arq Bras Cardiol 2020; 115:830-839. [PMID: 33295445 PMCID: PMC8452196 DOI: 10.36660/abc.20190317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/26/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Few studies have discussed the reasons for pharmacological undertreatment of Acute Coronary Syndrome (ACS). OBJECTIVES To determine the frequency and reasons for the non-administration and suspension of medications during in-hospital treatments of ACS in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. METHODS The present study analyzed the medical charts of the 563 participants in the ERICO study to evaluate the frequency and reasons for the non-administration and/or suspension of medications. Logistic regression models were built to analyze if sex, age ≥65 years of age, educational level, or ACS subtype were associated with (a) the non-administration of ≥1 medications; and (b) the non-administration or suspension of ≥1 medications. The significance level was set at 5%. RESULTS This study's sample included 58.1% males, with a median of 62 years of age. In 183 (32.5%) participants, ≥1 medications were not administered, while in 288 (51.2%), ≥1 medications were not administered or were suspended. The most common reasons were the risk of bleeding (aspirin, clopidogrel, and heparin), heart failure (beta blockers), and hypotension (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Individuals aged ≥65 (odds ratio [OR]:1.51; 95% confidence interval [95% CI]:1.05-2.19) and those with unstable angina (OR:1.72; 95% CI:1.07-2.75) showed a higher probability for the non-administration of ≥1 medication. Considering only patients with myocardial infarction, being ≥65 years of age was associated with both the non-administration and the non-administration or suspension of ≥1 medication. CONCLUSIONS Non-administration or suspension of ≥1 medication proved to be common in this ERICO study. Individuals of ≥65 years of age or with unstable angina showed a higher probability of the non-administration of ≥1 medication and may be undertreated in this scenario. (Arq Bras Cardiol. 2020; 115(5):830-839).
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Affiliation(s)
- Rafael C. O. Santos
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
| | - Isabela M. Bensenor
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
- Universidade de São PauloFaculdade de Medicina da USPDepartamento de Clínica MédicaSão PauloSPBrasilUniversidade de São Paulo - Departamento de Clínica Médica da Faculdade de Medicina da USP, São Paulo, SP - Brasil
| | - Alessandra C. Goulart
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
| | - Paulo A. Lotufo
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
- Universidade de São PauloFaculdade de Medicina da USPDepartamento de Clínica MédicaSão PauloSPBrasilUniversidade de São Paulo - Departamento de Clínica Médica da Faculdade de Medicina da USP, São Paulo, SP - Brasil
| | - Itamar S. Santos
- Universidade de São PauloHospital Universitário da USPCentro de Pesquisa Clínica e EpidemiológicaSão PauloSPBrasilUniversidade de São Paulo - Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da USP, São Paulo, SP - Brasil
- Universidade de São PauloFaculdade de Medicina da USPDepartamento de Clínica MédicaSão PauloSPBrasilUniversidade de São Paulo - Departamento de Clínica Médica da Faculdade de Medicina da USP, São Paulo, SP - Brasil
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Menichelli M, Neumann FJ, Ndrepepa G, Mayer K, Wöhrle J, Bernlochner I, Richardt G, Witzenbichler B, Sibbing D, Gewalt S, Angiolillo DJ, Lahu S, Hamm CW, Hapfelmeier A, Trenk D, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A. Age- and Weight-Adapted Dose of Prasugrel Versus Standard Dose of Ticagrelor in Patients With Acute Coronary Syndromes : Results From a Randomized Trial. Ann Intern Med 2020; 173:436-444. [PMID: 32687741 DOI: 10.7326/m20-1806] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The efficacy and safety of a reduced dose of prasugrel versus a standard dose of ticagrelor in elderly patients or those with a low body weight presenting with an acute coronary syndrome (ACS) are unknown. OBJECTIVE To investigate the effect of an age- and weight-adapted dose of prasugrel versus a standard dose of ticagrelor in patients with ACS. (ClinicalTrials.gov: NCT01944800). DESIGN Prespecified analysis of the multicenter, randomized ISAR-REACT 5 trial. SETTING 23 centers in Germany and Italy. PATIENTS 3997 patients with ACS planned for invasive management. INTERVENTION Participants were randomly assigned to receive a standard dose of ticagrelor or prasugrel (reduced dose in the elderly or low-weight group and standard dose in the neither elderly nor low-weight group). MEASUREMENTS The efficacy end point was a composite of death, myocardial infarction, or stroke, and the safety end point was bleeding, both at 12 months. RESULTS In the elderly or low-weight group, the efficacy end point occurred in 12.7% of patients assigned to receive prasugrel and 14.6% of those assigned to receive ticagrelor (hazard ratio [HR], 0.82 [95% CI, 0.60 to 1.14]); in the neither elderly nor low-weight group, the efficacy end point occurred in 4.8% of patients assigned to receive prasugrel and 7.3% of those assigned to receive ticagrelor (HR, 0.65 [CI, 0.48 to 0.88]; P for interaction > 0.2). In the elderly or low-weight group, Bleeding Academic Research Consortium type 3 to 5 bleeding occurred in 8.1% of patients assigned to receive prasugrel and 10.6% of those assigned to receive ticagrelor (HR, 0.72 [0.46 to 1.12]), and in 3.7% and 3.8%, respectively, of patients in the neither elderly nor low-weight group (HR, 0.98 [CI, 0.65 to 1.47]; P for interaction > 0.2). LIMITATION The study is a subgroup analysis. CONCLUSION In elderly or low-weight patients with ACS, a reduced dose of prasugrel compared with the standard dose of ticagrelor is associated with maintained anti-ischemic efficacy while protecting these patients against the excess risk for bleeding. PRIMARY FUNDING SOURCE German Center for Cardiovascular Research and Deutsches Herzzentrum München.
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Affiliation(s)
| | - Franz-Josef Neumann
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (F.N., D.T.)
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | - Katharina Mayer
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | - Jochen Wöhrle
- Medical Campus Lake Constance, Friedrichshafen, Germany (J.W.)
| | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (I.B.)
| | - Gert Richardt
- Heart Center Bad Segeberg, Bad Segeberg, Germany (G.R.)
| | | | - Dirk Sibbing
- Klinik der Universität München, Ludwig-Maximilians-Universität, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (D.S.)
| | - Senta Gewalt
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | | | - Shqipdona Lahu
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany (G.N., K.M., S.G., S.L.)
| | - Christian W Hamm
- Heart Center, Campus Kerckhoff of Justus-Liebig-University, Giessen, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany (C.W.H.)
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute of Medical Informatics, Statistics and Epidemiology, Munich, Germany (A.H.)
| | - Dietmar Trenk
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany (F.N., D.T.)
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I, Klinikum rechts der Isar, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (K.L.)
| | - Heribert Schunkert
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (H.S., S.S., A.K.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (H.S., S.S., A.K.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München and Technische Universität München, Munich, Germany, and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (H.S., S.S., A.K.)
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Marquis-Gravel G, Neely ML, Valgimigli M, Costa F, Van Klaveren D, Altner R, Bhatt DL, Armstrong PW, Fox KAA, White HD, Ohman EM, Roe MT. Long-Term Bleeding Risk Prediction with Dual Antiplatelet Therapy After Acute Coronary Syndromes Treated Without Revascularization. Circ Cardiovasc Qual Outcomes 2020; 13:e006582. [PMID: 32862694 DOI: 10.1161/circoutcomes.120.006582] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Longitudinal bleeding risk scores have been validated in patients treated with dual antiplatelet therapy (DAPT) following percutaneous coronary intervention. How these scores apply to the population of patients with acute coronary syndrome (ACS) treated without revascularization remains unknown. The objective was to evaluate and compare the performances of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) bleeding risk scores in the medically managed patients with ACS treated with DAPT. METHODS AND RESULTS TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) was a double-blind, placebo-controlled randomized trial conducted from 2008 to 2012 over a median follow-up of 17.0 months in 966 sites (52 countries). High-risk patients with unstable angina or non-ST-segment-elevation myocardial infarction who did not undergo revascularization were randomized to prasugrel or clopidogrel. The PRECISE-DAPT, PARIS, and DAPT (bleeding component) risk scores were applied in the TRILOGY ACS population to evaluate their performance to predict adjudicated non-coronary artery bypass grafting-related GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe/life-threatening/moderate and TIMI (Thrombolysis in Myocardial Infarction) major/minor bleeding with time-dependent c-indices. Among the 9326 participants, median age was 66 years (interquartile range, 59-74 years), and 3650 were females (39.1%). A total of 158 (1.69%) GUSTO severe/life-threatening/moderate and 174 (1.87%) TIMI major/minor non-coronary artery bypass grafting bleeding events occurred. The c-indices (95% CI) of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) scores through 12 months were 0.716 (0.677-0.758), 0.693 (0.658-0.733), and 0.674 (0.637-0.713), respectively, for GUSTO bleeding and 0.624 (0.582-0.666), 0.612 (0.578-0.651), and 0.608 (0.571-0.649), respectively, for TIMI bleeding. There was no significant difference in the c-indices of each score based upon pairwise comparisons. CONCLUSIONS Among medically managed patients with ACS treated with DAPT, the performances of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) scores were reasonable and similar to their performances in the derivation percutaneous coronary intervention populations. Bleeding risk scores may be used to predict longitudinal bleeding risk in patients with ACS treated with DAPT without revascularization and help support shared decision making. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00699998.
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Affiliation(s)
| | - Megan L Neely
- Duke Clinical Research Institute, Durham, NC (G.M.G., M.L.N., R.A., E.M.O., M.T.R.)
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Switzerland (M.V., F.C.)
| | - Francesco Costa
- Swiss Cardiovascular Center Bern, Bern University Hospital, Switzerland (M.V., F.C.).,Department of Clinical and Experimental Medicine, Policlinic "G. Martino", University of Messina, Italy (F.C.)
| | - David Van Klaveren
- Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands (D.V.K.).,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (D.V.K.)
| | - Rituparna Altner
- Duke Clinical Research Institute, Durham, NC (G.M.G., M.L.N., R.A., E.M.O., M.T.R.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Paul W Armstrong
- Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, Canada (P.W.A.)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC (G.M.G., M.L.N., R.A., E.M.O., M.T.R.).,Division of Cardiology, Duke University School of Medicine, Durham, NC (E.M.O., M.T.R.)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, NC (G.M.G., M.L.N., R.A., E.M.O., M.T.R.).,Division of Cardiology, Duke University School of Medicine, Durham, NC (E.M.O., M.T.R.)
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Li Y. Diagnostic Model for In-Hospital Bleeding in Patients with Acute ST-Segment Elevation Myocardial Infarction: Algorithm Development and Validation. JMIR Med Inform 2020; 8:e20974. [PMID: 32795995 PMCID: PMC7455869 DOI: 10.2196/20974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 11/22/2022] Open
Abstract
Background Bleeding complications in patients with acute ST-segment elevation myocardial infarction (STEMI) have been associated with increased risk of subsequent adverse consequences. Objective The objective of our study was to develop and externally validate a diagnostic model of in-hospital bleeding. Methods We performed multivariate logistic regression of a cohort for hospitalized patients with acute STEMI in the emergency department of a university hospital. Participants: The model development data set was obtained from 4262 hospitalized patients with acute STEMI from January 2002 to December 2013. A set of 6015 hospitalized patients with acute STEMI from January 2014 to August 2019 were used for external validation. We used logistic regression analysis to analyze the risk factors of in-hospital bleeding in the development data set. We developed a diagnostic model of in-hospital bleeding and constructed a nomogram. We assessed the predictive performance of the diagnostic model in the validation data sets by examining measures of discrimination, calibration, and decision curve analysis (DCA). Results In-hospital bleeding occurred in 112 of 4262 participants (2.6%) in the development data set. The strongest predictors of in-hospital bleeding were advanced age and high Killip classification. Logistic regression analysis showed differences between the groups with and without in-hospital bleeding in age (odds ratio [OR] 1.047, 95% CI 1.029-1.066; P<.001), Killip III (OR 3.265, 95% CI 2.008-5.31; P<.001), and Killip IV (OR 5.133, 95% CI 3.196-8.242; P<.001). We developed a diagnostic model of in-hospital bleeding. The area under the receiver operating characteristic curve (AUC) was 0.777 (SD 0.021, 95% CI 0.73576-0.81823). We constructed a nomogram based on age and Killip classification. In-hospital bleeding occurred in 117 of 6015 participants (1.9%) in the validation data set. The AUC was 0.7234 (SD 0.0252, 95% CI 0.67392-0.77289). Conclusions We developed and externally validated a diagnostic model of in-hospital bleeding in patients with acute STEMI. The discrimination, calibration, and DCA of the model were found to be satisfactory. Trial Registration ChiCTR.org ChiCTR1900027578; http://www.chictr.org.cn/showprojen.aspx?proj=45926
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Affiliation(s)
- Yong Li
- Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Spartalis M, Tzatzaki E, Spartalis E, Paschou SA, Athanasiou A, Iliopoulos DC, Siasos G, Voudris V. Prasugrel in the treatment of acute coronary syndrome. Future Cardiol 2020; 16:559-568. [PMID: 32390477 DOI: 10.2217/fca-2020-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Dual antiplatelet therapy is the mainstay therapy in patients with acute coronary syndrome. The combination of aspirin and a P2Y12 inhibitor in patients who receive a coronary stent reduces the rate of stent thrombosis and the rates of major adverse cardiovascular events. The newer P2Y12 inhibitors (prasugrel and ticagrelor) have better efficacy than clopidogrel. Prasugrel provides greater inhibition of platelet aggregation and has a rapid onset of action. Current acute coronary syndrome guidelines recommend the use of both newer P2Y12 inhibitors. However, emerging data have shown that prasugrel is more efficient than ticagrelor in reducing the incidence of nonfatal myocardial infarction, stroke or cardiovascular death, without increased risk of major bleeding.
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Affiliation(s)
- Michael Spartalis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery & Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Stavroula A Paschou
- 1st Department of Cardiology, Hippokration Hospital, National & Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonios Athanasiou
- Laboratory of Experimental Surgery & Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery & Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Gerasimos Siasos
- 1st Department of Cardiology, Hippokration Hospital, National & Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Vassilis Voudris
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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Crimi G, De Rosa R, Mandurino-Mirizzi A, Morici N, Alberti LP, Savonitto S, De Servi S. De-escalating dual antiplatelet therapy in patients with acute coronary syndromes: the right strategy to harmonize time-dependent ischemic and bleeding risk in elderly patients? J Cardiovasc Med (Hagerstown) 2020; 21:281-285. [PMID: 32108125 DOI: 10.2459/jcm.0000000000000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: The European Society of Cardiology guidelines for myocardial revascularization state that de-escalation of P2Y12 inhibitor treatment guided by platelet function testing may be considered for acute coronary syndrome (ACS) patients deemed unsuitable for 12-month potent platelet inhibition. De-escalation strategy aim is to harmonize the time-dependency of thrombotic risk, which is high in the first month after ACS, then decreases exponentially, with bleeding risk, which tends to remain more stable after the procedure-related peak. Harmonizing time-dependency of clinical events may be particularly relevant in those at high risk, such as the elderly patients with ACS in whom an individualized antiplatelet therapy may be more appropriate than a 'one-size-fits all' approach. In this review, we outline the current medical evidence on the topic of dual antiplatelet therapy de-escalation. In addition, we include insights from the Elderly ACS 2 study and recently published post-hoc analyses conducted by the authors' consortium, which further expands current knowledge.
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Affiliation(s)
- Gabriele Crimi
- SC. Cardiologia, Fondazione Policlinico San Matteo, Pavia.,Cardiologia Interventistica, Dipartimento CardioToracoVascolare, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Roberta De Rosa
- Department of Medicine, Surgery and Dentistry, Schola Medica Salernitana, University of Salerno
| | | | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan
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Abstract
Platelets are small, anucleated effector cells that play an important role in linking the hemostatic and inflammatory processes in the body. Platelet function is known to be altered under various inflammatory conditions including aging. A gain in platelet function during aging can increase the risk of thrombotic events, such as stroke and acute myocardial infarction. Anti-platelet therapy is designed to reduce risk of serious cerebrovascular and cardiovascular events, but the adverse consequences of therapy, such as risk for bleeding increases with aging as well. Age-associated comorbidities such as obesity, diabetes, and hyperlipidemia also contribute to increased platelet activity and thus can enhance the risk of thrombosis. Therefore, identification of unique mechanisms of platelet dysfunction in aging and in age-associated comorbidities is warranted to design novel antiplatelet drugs. This review outlines some of the current areas of research on aging-related mechanisms of platelet hyperactivity and addresses the clinical urgency for designing anti-platelet therapies toward novel molecular targets in the aging population.
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Affiliation(s)
- Krishna S Iyer
- Department of Internal Medicine, University of Iowa , Iowa city, USA
| | - Sanjana Dayal
- Department of Internal Medicine, University of Iowa , Iowa city, USA
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Koyabu Y, Abe S, Sakuma M, Kanaya T, Obi S, Yoneda S, Toyoda S, Nakajima T, Inoue T. Short-term Safety and Mid-term Efficacy of Prasugrel Versus Clopidogrel in Patients Undergoing Percutaneous Coronary Intervention. Intern Med 2019; 58:2315-2322. [PMID: 31118376 PMCID: PMC6746638 DOI: 10.2169/internalmedicine.2262-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Although several clinical trials have shown that the mid- and long-term safety and efficacy of prasugrel are better than those of clopidogrel after percutaneous coronary intervention (PCI), there are few data regarding the short-term safety. Methods In this study, we retrospectively analyzed the short-term (72 hours) PCI-related bleeding complications and mid-term (12 months) efficacy in 250 consecutive coronary artery disease patients who underwent PCI and received aspirin plus prasugrel (prasugrel group; 67.7±10.0 years, 200 men). Patients The comparison group consisted of 250 age- and gender-matched patients who received aspirin plus clopidogrel (clopidogrel group: 67.2±11.2 years, 199 men). Results The incidence of a composite of PCI-related bleeding complications in the acute phase post-PCI was significantly higher in the prasugrel group than in the clopidogrel group (22.4% vs. 13.2%, p=0.007), although the incidence of non-PCI-related bleeding complications over 12 months was comparable between the 2 groups. The cumulative incidence of major cardiovascular events (MACEs) was comparable between the prasugrel and clopidogrel groups (log-rank test; p=0.561). A multivariate logistic regression analysis of the 250 prasugrel-treated patients showed that acute coronary syndrome tended to be negatively associated with the incidence of PCI-related bleeding complications (p=0.061). Conclusion Prasugrel and clopidogrel may have similar efficacy for preventing cardiovascular events as the post-PCI antiplatelet regimen; however, prasugrel should be used cautiously because of the risk of PCI-related bleeding complications.
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Affiliation(s)
- Yota Koyabu
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Shichiro Abe
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Masashi Sakuma
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Tomoaki Kanaya
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Syotaro Obi
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Shuichi Yoneda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Toshiaki Nakajima
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
| | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University, Japan
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Aradi D, Gross L, Trenk D, Geisler T, Merkely B, Kiss RG, Komócsi A, Dézsi CA, Ruzsa Z, Ungi I, Rizas KD, May AE, Mügge A, Zeiher AM, Holdt L, Huber K, Neumann FJ, Koltowski L, Huczek Z, Hadamitzky M, Massberg S, Sibbing D. Platelet reactivity and clinical outcomes in acute coronary syndrome patients treated with prasugrel and clopidogrel: a pre-specified exploratory analysis from the TROPICAL-ACS trial. Eur Heart J 2019; 40:1942-1951. [DOI: 10.1093/eurheartj/ehz202] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/31/2019] [Accepted: 04/17/2019] [Indexed: 01/18/2023] Open
Abstract
Abstract
Aims
The value of platelet function testing (PFT) in predicting clinical outcomes and guiding P2Y12-inhibitor treatment is uncertain. In a pre-specified sub-study of the TROPICAL-ACS trial, we assessed ischaemic and bleeding risks according to high platelet reactivity (HPR) and low platelet reactivity (LPR) to ADP in patients receiving uniform prasugrel vs. PFT-guided clopidogrel or prasugrel.
Methods and results
Acute coronary syndrome patients with PFT done 14 days after hospital discharge were included with prior randomization to uniform prasugrel for 12 months (control group, no treatment modification) vs. early de-escalation from prasugrel to clopidogrel and PFT-guided maintenance treatment (HPR: switch-back to prasugrel, non-HPR: clopidogrel). The composite ischaemic endpoint included cardiovascular death, myocardial infarction, or stroke, while key safety outcome was Bleeding Academic Research Consortium (BARC) 2–5 bleeding, from PFT until 12 months. We identified 2527 patients with PFT results available: 1266 were randomized to the guided and 1261 to the control group. Before treatment adjustment, HPR was more prevalent in the guided group (40% vs. 15%), while LPR was more common in control patients (27% vs. 11%). Compared to control patients without HPR on prasugrel (n = 1073), similar outcomes were observed in guided patients kept on clopidogrel [n = 755, hazard ratio (HR): 1.06 (0.57–1.95), P = 0.86] and also in patients with HPR on clopidogrel switched to prasugrel [n = 511, HR: 0.96 (0.47–1.96), P = 0.91]. In contrast, HPR on prasugrel was associated with a higher risk for ischaemic events in control patients [n = 188, HR: 2.16 (1.01–4.65), P = 0.049]. Low platelet reactivity was an independent predictor of bleeding [HR: 1.74 (1.18–2.56), P = 0.005], without interaction (Pint = 0.76) between study groups.
Conclusion
Based on this substudy of a randomized trial, selecting prasugrel or clopidogrel based on PFT resulted in similar ischaemic outcomes as uniform prasugrel therapy without HPR. Although infrequent, HPR on prasugrel was associated with increased risk of ischaemic events. Low platelet reactivity was a strong and independent predictor of bleeding both on prasugrel and clopidogrel.
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Affiliation(s)
- Dániel Aradi
- Department of Active Cardiology, Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University Budapest, 2 Gyógy Tér, Balatonfüred, Hungary
- Department of Cardiology, Heart and Vascular Centre, Semmelweis University Budapest, Budapest, Hungary
| | - Lisa Gross
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, Tübingen, Germany
| | - Béla Merkely
- Department of Cardiology, Heart and Vascular Centre, Semmelweis University Budapest, Budapest, Hungary
| | | | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, University of Pécs, Pécs, Hungary
| | - Csaba András Dézsi
- Department of Cardiology, Petz Aladár County Hospital Győr, Győr, Hungary
| | - Zoltán Ruzsa
- Department of Cardiology, Heart and Vascular Centre, Semmelweis University Budapest, Budapest, Hungary
| | - Imre Ungi
- Department of Cardiology, University of Szeged, Szeged, Hungary
| | - Konstantinos D Rizas
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
| | - Andreas E May
- Department of Cardiology, Innere Medizin I, Klinikum Memmingen, Memmingen, Germany
| | - Andreas Mügge
- Department of Cardiology, Katholisches Klinikum Bochum, St. Josef Hospital, Bochum, Germany
| | - Andreas M Zeiher
- Department of Cardiology, Universitätsklinikum Frankfurt, Frankfurt/Main, Germany
| | - Lesca Holdt
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Sigmund Freud Private University, Medical School, Wien, Austria
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Centre Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Lukasz Koltowski
- 1 Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Zenon Huczek
- 1 Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, Deutsches Herzzentrum München, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Munich, Germany
- Partner Site Munich Heart Alliance, DZHK (German Center for Cardiovascular Research), Munich, Germany
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Bleeding risk assessment in elderly patients with acute coronary syndrome. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2019; 16:145-150. [PMID: 30923546 PMCID: PMC6431601 DOI: 10.11909/j.issn.1671-5411.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, elderly people represent a growing population segment with a well known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts. Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.
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Estrategia invasiva frente a conservadora en pacientes frágiles con IAMSEST. Diseño del ensayo clínico MOSCA-FRAIL. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.01.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Jeger RV, Pfisterer M, Vogt DR, Galatius S, Abildgaard U, Naber C, Alber H, Eberli F, Kurz DJ, Pedrazzini G, Vuilliomenet A, Weilenmann D, Rickli H, Hansen KW, Rickenbacher P, Conen D, Müller C, Osswald S, Gilgen N, Kaiser C. Competing risks of major bleeding and thrombotic events with prasugrel-based dual antiplatelet therapy after stent implantation - An observational analysis from BASKET-PROVE II. PLoS One 2019; 14:e0210821. [PMID: 30645635 PMCID: PMC6333357 DOI: 10.1371/journal.pone.0210821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/24/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) prevents thrombotic events after coronary stent implantation but may induce bleedings, specifically in elderly patients. However, a competitive risk analysis is lacking. OBJECTIVES To assess the determinants of major bleeding and the balance between the competing risks of major bleeding and thrombotic events during prasugrel-based DAPT after stent implantation. METHODS Overall, 2,291 patients randomized to drug-eluting or bare metal stents and treated with prasugrel 10mg/day for 1 year were followed over 2 years for major bleeding (BARC 3/5) and thrombotic events (cardiac death, myocardial infarction, definitive/probable stent thrombosis). Prasugrel dose was reduced to 5mg in patients >75 years and/or <60kg. Predictors of major bleeding and competing risks of major bleeding and thrombotic events were assessed. RESULTS Two-year rates of major bleeding and thrombotic events were 2.9% and 9.0%, respectively. The only independent predictor of major bleeding was age (hazard ratio per year increase 1.05 [1.02,1.07], p<0.001). The relationship between major bleeding and age was non-linear, with lowest hazard ratios at 57 years and an exponential increase only above 65 years. In contrast, the relationship between thrombotic events and age was linear and continuously increasing with older age. While the competing risk of thrombotic events was higher than that of major bleeding in younger patients, the two risks were similar in older patients. After discontinuation of prasugrel, bleeding events leveled off in all patients, while thrombotic events continued to increase. CONCLUSIONS In prasugrel-based DAPT, age is the strongest risk factor for major bleeding, increasing exponentially >65 years. In younger patients, thrombotic events represent a higher risk than bleeding, while thrombotic and bleeding risks were similar in older patients. Important clinical implications relate to prasugrel dose in the elderly, duration of DAPT and the competing risk balance necessitating individualized treatment decisions.
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Affiliation(s)
- Raban V. Jeger
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
- * E-mail:
| | - Matthias Pfisterer
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Deborah R. Vogt
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Søren Galatius
- Cardiology, Gentofte University Hospital Copenhagen, Hellerup, Denmark
| | - Ulrik Abildgaard
- Cardiology, Gentofte University Hospital Copenhagen, Hellerup, Denmark
| | | | - Hannes Alber
- Cardiology, University Hospital Innsbruck and Klinikum Klagenfurt am Wörthersee, Innsbruck and Klagenfurt am Wörthersee, Austria
| | - Franz Eberli
- Cardiology, Triemli Hospital, Zürich, Switzerland
| | | | | | | | | | - Hans Rickli
- Cardiology, State Hospital, St. Gallen, Switzerland
| | - Kim Wadt Hansen
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | | | - David Conen
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
- Population Health Research Institute, McMaster University, Hamilton ON, Canada
| | - Christian Müller
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Nicole Gilgen
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Christoph Kaiser
- Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
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41
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Guo CG, Chen L, Chan EW, Cheung KS, Isshiki T, Wong ICK, Leung WK. Systematic review with meta-analysis: the risk of gastrointestinal bleeding in patients taking third-generation P2Y 12 inhibitors compared with clopidogrel. Aliment Pharmacol Ther 2019; 49:7-19. [PMID: 30506985 DOI: 10.1111/apt.15059] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/26/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ticagrelor and prasugrel are third-generation oral P2Y12 receptor antagonists with rapid onset and pronounced platelet inhibition. However, higher overall bleeding rates have been reported for these agents when compared with clopidogrel. AIM To compare the risk of gastrointestinal bleeding (GIB) among users of third-generation P2Y12 inhibitors with clopidogrel. METHODS We systematically searched for published randomised controlled trials of ticagrelor or prasugrel versus clopidogrel until September 2018. The primary outcome was the risk of GIB among users of third-generation P2Y12 inhibitors when compared to clopidogrel, expressed as risk ratio (RR) and 95% confidence interval (CI). The rates of non-coronary artery bypass graft (CABG) major bleeding, life-threatening bleeding, fatal bleeding, and intracranial bleeding were analysed as secondary outcomes. RESULTS Forty-one studies were included in the analysis of non-CABG major bleeding, of which 12 were included in the analysis of GIB including 58 678 patients. Third-generation P2Y12 inhibitors were associated with higher risk of GIB as compared with clopidogrel (RR 1.28, 95% CI 1.13-1.46). The findings were consistent for upper (RR 1.32, 95% CI 1.05-1.67) and unspecified GIB (RR 1.25, 95% CI 1.01-1.53), but not lower GIB (RR 1.25, 95% CI 0.95-1.65). Subgroup analysis showed higher GIB risk in prasugrel studies (RR 1.40, 95% CI 1.10-1.77) than in ticagrelor studies (RR 1.15, 95% CI 0.94-1.39). Third-generation P2Y12 inhibitors also increased the risk of non-CABG major bleeding (RR 1.18, 95% CI 1.08-1.28). CONCLUSION Third-generation P2Y12 inhibitors were associated with increased risk of GIB and non-CABG major bleeding when compared with clopidogrel.
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Affiliation(s)
- Chuan-Guo Guo
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Lijia Chen
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Ka Shing Cheung
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Takaaki Isshiki
- Cardiovascular Center, Ageo Central General Hospital, Ageo, Saitama, Japan
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Wai K Leung
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
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Sex And Prognostic Significance of Self-Reported Frailty in Non-ST-Segment Elevation Acute Coronary Syndromes: Insights From the TRILOGY ACS Trial. Can J Cardiol 2018; 35:430-437. [PMID: 30935633 DOI: 10.1016/j.cjca.2018.12.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 12/05/2018] [Accepted: 12/26/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The effect of sex on self-reported frailty in acute coronary syndromes (ACS) is unclear. We examined the prevalence of self-reported frailty and its association with all-cause death among men and women. METHODS Elderly (≥ 65 years) male (n = 2691) and female (n = 2305) patients with ACS enrolled in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial were screened using the Fried Frailty Index. Sex differences in prevalence of frailty symptoms and categories (not frail; prefrail [1 to 2 symptoms]; and frail [≥ 3 symptoms]) and their prognostic importance were examined. RESULTS Women were older and had higher rates of comorbidities than men. A total of 739 (27.5%) men and 645 (28%) women reported ≥ 1 frailty symptom. Prevalence of frailty increased with age among men but not women. During a median follow-up of 17.3 months, 353 (13.1%) men and 266 (11.5%) women died. After adjusting for age, prefrail men had a 35% increased risk (hazard ratio [HR] 1.35; 95% confidence interval [CI], 1.07-1.71), and frail men had an 80% increased risk (HR 1.80; 95% CI, 1.22-2.67) of death relative to not-frail men. The age-adjusted HR for death in prefrail women was 1.40 (95% CI, 1.07-1.84), and 1.55 (95% CI, 0.96-2.49) in frail women relative to not-frail women. Self-reported slow walk time and decreased physical activity appeared to provide the most prognostic information. CONCLUSION Self-reported frailty was similar among men and women with ACS. Frailty increased with age only among men, in whom it added more prognostic information. Patient-reported frailty may identify elderly patients with ACS, particularly men, at high-risk of mortality.
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Cavallari LH, Obeng AO. Genetic Determinants of P2Y 12 Inhibitors and Clinical Implications. Interv Cardiol Clin 2018; 6:141-149. [PMID: 27886818 DOI: 10.1016/j.iccl.2016.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
There is significant interpatient variability in clopidogrel effectiveness, which is due in part to cytochrome P450 (CYP) 2C19 genotype. Approximately 30% of individuals carry CYP2C19 loss-of-function alleles, which have been consistently shown to reduce clopidogrel effectiveness after an acute coronary syndrome and percutaneous coronary intervention. Guidelines recommend consideration of prasugrel or ticagrelor in these patients. A clinical trial examining outcomes with CYP2C19 genotype-guided antiplatelet therapy is ongoing. In the meantime, based on the evidence available to date, several institutions have started clinically implementing CYP2C19 genotyping to assist with antiplatelet selection after percutaneous coronary intervention.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics, University of Florida, 1333 Center Drive, PO Box 100486, Gainesville, FL 32610, USA.
| | - Aniwaa Owusu Obeng
- Division of General Internal Medicine, Department of Medicine, The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, USA; Department of Pharmacy, The Mount Sinai Hospital, New York, NY, USA
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Kochar A, Chen AY, Sharma PP, Pagidipati NJ, Fonarow GC, Cowper PA, Roe MT, Peterson ED, Wang TY. Long-Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice. J Am Heart Assoc 2018; 7:JAHA.117.007230. [PMID: 29960995 PMCID: PMC6064921 DOI: 10.1161/jaha.117.007230] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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 There is limited information about the long-term survival of older patients after myocardial infarction (MI). METHODS AND RESULTS CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) was a registry of MI patients treated at 568 US hospitals from 2001 to 2006. We linked MI patients aged ≥65 years in CRUSADE to their Medicare data to ascertain long-term mortality (defined as 8 years post index event). Long-term unadjusted Kaplan-Meier mortality curves were examined among patients stratified by revascularization status. A landmark analysis conditioned on surviving the first year post-MI was conducted. We used multivariable Cox regression to compare mortality risks between ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction patients. Among 22 295 MI patients ≥ age 65 years (median age 77 years), we observed high rates of evidence-based medication use at discharge: aspirin 95%, β-blockers 94%, and statins 81%. Despite this, mortality rates were high: 24% at 1 year, 51% at 5 years, and 65% at 8 years. Eight-year mortality remained high among patients who underwent percutaneous coronary intervention (49%), coronary artery bypass graft (46%), and among patients who survived the first year post-MI (59%). Median survival was 4.8 years (25th, 75th percentiles 1.1, 8.5); among patients aged 65-74 years it was 8.2 years (3.3, 8.9) while for patients aged ≥75 years it was 3.1 years (0.6, 7.6). Eight-year mortality was lower among ST-segment-elevation myocardial infarction than non-ST-segment-elevation myocardial infarction patients (53% versus 67%); this difference was not significant after adjustment (hazard ratio 0.94, 95% confidence interval, 0.88-1.00). CONCLUSIONS Long-term mortality remains high among patients with MI in routine clinical practice, even among revascularized patients and those who survived the first year.
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Affiliation(s)
- Ajar Kochar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Anita Y Chen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Savonitto S, Ferri LA, Piatti L, Grosseto D, Piovaccari G, Morici N, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Ferrario M, Murena E, Sibilio G, Tondi S, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Rogacka R, Antonicelli R, Cesana BM, De Luca L, Ottani F, De Luca G, Piscione F, Moffa N, De Servi S, Bolognese L, Bovenzi F, Steffenino G, Santilli I, Bassanelli G, Sacco A, Canziani F, Ferri M, Lo Jacono E, Canosi U, Fornaro G, Leoncini M, Rosa Conte M, Farina R, Stefanin C, Di Pede F, Chella P, Chiara Nardoni M, Tamburrini P, Trimarco B, Galasso G, Elia R, Bolognese L, Grotti S, Bovenzi F, Borrelli L, Tamburino C, Capranzano P, Francaviglia B, Campana C, Bonatti R, Martinoni A, Abate F, Coscarelli S, Rubartelli P, Villani GQ, Rossini R. Comparison of Reduced-Dose Prasugrel and Standard-Dose Clopidogrel in Elderly Patients With Acute Coronary Syndromes Undergoing Early Percutaneous Revascularization. Circulation 2018; 137:2435-2445. [DOI: 10.1161/circulationaha.117.032180] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/02/2018] [Indexed: 11/16/2022]
Abstract
Background:
Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on-clopidogrel platelet reactivity compared with younger patients. Prasugrel 5 mg provides more predictable platelet inhibition compared with clopidogrel in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding.
Methods:
In a multicenter, randomized, open-label, blinded end point trial, we compared a once-daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years of age with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was the composite of mortality, myocardial infarction, disabling stroke, and rehospitalization for cardiovascular causes or bleeding within 1 year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg.
Results:
Enrollment was interrupted, according to prespecified criteria, after a planned interim analysis, when 1443 patients (40% women; mean age, 80 years) had been enrolled with a median follow-up of 12 months, because of futility for efficacy. The primary end point occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (hazard ratio, 1.007; 95% confidence interval, 0.78–1.30;
P
=0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel versus 1.9% with clopidogrel (odds ratio, 0.36; 95% confidence interval, 0.13–1.00;
P
=0.06). Bleeding Academic Research Consortium types 2 and greater rates were 4.1% with prasugrel versus 2.7% with clopidogrel (odds ratio, 1.52; 95% confidence interval, 0.85–3.16;
P
=0.18).
Conclusions:
The present study in elderly patients with acute coronary syndromes showed no difference in the primary end point between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in light of the premature termination of the trial.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01777503.
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Affiliation(s)
| | | | - Luigi Piatti
- Ospedale Manzoni, Lecco, Italy (S.S., L.A.F., L.P.)
| | | | | | - Nuccia Morici
- Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy (N. Morici, I.B.)
| | - Irene Bossi
- Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy (N. Morici, I.B.)
| | | | - Giovanni Tortorella
- Istituto di Ricerca e Cura a Carattere Scientifico Arcispedale S. Maria Nuova, Reggio Emilia, Italy (G.T.)
| | | | | | - Ernesto Murena
- Ospedale S. Maria delle Grazie, Pozzuoli, Italy (E.M., G.S.)
| | | | | | - Anna Toso
- Ospedale S. Stefano, Prato, Italy (A.T.)
| | | | | | - Elena Corrada
- Humanitas Clinical and Research Center, Rozzano, Italy (E.C.)
| | | | | | | | | | | | - Renata Rogacka
- Azienda Ospedaliera di Desio e Vimercate, Desio, Italy (R.R.)
| | | | - Bruno M. Cesana
- Statistics and Biomathematics Unit, Department of Molecular and Transactional Medicine, University of Brescia, Italy (B.M.C.)
| | | | | | - Giuseppe De Luca
- Azienda Ospedaliera-Universitaria “Maggiore della Carità,” Eastern Piedmont University, Novara, Italy (G.D.L.)
| | - Federico Piscione
- Department of Medicine, Surgery and Dentistry–Schola Medica Salernitana, University of Salerno, Italy (F.P.)
| | - Nadia Moffa
- Mediolanum Cardio Research, Milan, Italy (N. Moffa)
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Cavender MA, Bhatt DL, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Prats J, Elkin S, Deliargyris EN, Mahaffey KW, White HD, Harrington RA. Cangrelor in Older Patients Undergoing Percutaneous Coronary Intervention: Findings From CHAMPION PHOENIX. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.117.005257. [PMID: 28801539 DOI: 10.1161/circinterventions.117.005257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Older patients treated with percutaneous coronary intervention are at increased risk of periprocedural events. METHODS AND RESULTS CHAMPION (cangrelor versus standard therapy to achieve optimal management of platelet inhibition) PHOENIX randomized 11 145 patients to cangrelor or clopidogrel. We sought to determine the outcomes in the prespecified subgroup of patients ≥75 years old (n=2010; 18%). Cangrelor resulted in directionally consistent effects on the primary end point (death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) in patients ≥75 years old (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.50-1.02) and in those <75 years old (OR, 0.81; 95% CI, 0.67-0.98; P [interaction]=0.55). Age ≥75 years was an independent predictor of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate/severe bleeding (1.0% versus 0.3%; adjusted OR, 2.94; 95% CI, 1.28-6.77; P=0.01) when compared with patients <75 years old. There was no significant difference in GUSTO moderate/severe bleeding with cangrelor versus clopidogrel (1.1% versus 1.0%; OR, 1.07; 95% CI 0.45-2.53) in patients ≥75 years old or in those <75 years old (0.4% versus 0.2%; OR, 2.24; 95% CI, 1.02-4.93; P [interaction]=0.21). For the net composite end point of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis plus GUSTO moderate/severe bleeding, the OR for cangrelor in those ≥75 years old was 0.75 (6.4% versus 8.3%; 95% CI, 0.54-1.05; P=0.09). The effects were similar in those <75 years old (4.9% versus 5.8%; OR, 0.85; 95% CI, 0.70-1.02; P=0.08; P [interaction]=0.53). CONCLUSIONS Patients ≥75 years old have an overall ≈3-fold increased odds of moderate/severe bleeding. Cangrelor, when compared with clopidogrel, provides similar efficacy and in patients ≥75 years old as in those <75 years old but does not increase the risk of major bleeding. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01156571.
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Affiliation(s)
- Matthew A Cavender
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Deepak L Bhatt
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.).
| | - Gregg W Stone
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Ph Gabriel Steg
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - C Michael Gibson
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Christian W Hamm
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Matthew J Price
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Jayne Prats
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Steven Elkin
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Efthymios N Deliargyris
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Kenneth W Mahaffey
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Harvey D White
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
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Bundhun PK, Huang F. Post percutaneous coronary interventional adverse cardiovascular outcomes and bleeding events observed with prasugrel versus clopidogrel: direct comparison through a meta-analysis. BMC Cardiovasc Disord 2018; 18:78. [PMID: 29720092 PMCID: PMC5932806 DOI: 10.1186/s12872-018-0820-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 04/26/2018] [Indexed: 12/31/2022] Open
Abstract
Background Due to limitations associated with clopidogrel following percutaneous coronary intervention (PCI), other newer oral anti-platelet agents are being studied. We aimed to systematically carry out a direct comparison of outcomes observed with prasugrel versus clopidogrel following PCI. Methods Common online searched databases (The Cochrane library, EMBASE, MEDLINE and Google scholar) were used to retrieve relevant publications. Primary endpoints were the adverse cardiovascular outcomes. Secondary outcomes were the bleeding events. This analysis was carried out by RevMan 5.3, whereby odds ratios (OR) and 95% confidence intervals (CI) were considered as the statistical parameters. Results Eight studies with a total number of 18,122 participants were included in this direct analysis. Prasugrel was associated with significantly lower adverse cardiovascular outcomes in comparison to clopidogrel following PCI. All-cause mortality, myocardial infarction, stroke, stent thrombosis and major adverse cardiac events were all significantly lower with prasugrel (OR: 0.47, 95% CI: 0.35–0.63; P = 0.0001), (OR: 0.68, 95% CI: 0.57–0.80; P = 0.00001), (OR: 0.60, 95% CI: 0.38–0.96; P = 0.03), (OR: 0.46, 95% CI: 0.30–0.72; P = 0.0006) and (OR: 0.61, 95% CI: 0.53–0.70; P = 0.00001) respectively. When the bleeding outcomes were analyzed, Thrombolysis in Myocardial Infarction (TIMI) defined major and minor bleeding were not significantly different (OR: 0.91, 95% CI: 0.66–1.27; P = 0.59) and (OR: 1.16, 95% CI: 0.85–1.59; P = 0.35) respectively. However, the combined ‘all bleeding events’ was significantly higher with prasugrel (OR: 1.32, 95% CI: 1.03–1.70; P = 0.03), but when patients with STEMI and those undergoing elective PCI were separately analyzed, no significant difference in overall bleeding was observed. Conclusion Adverse cardiovascular outcomes were significantly lower with the use of prasugrel in comparison to clopidogrel following PCI. In addition, TIMI defined major and minor bleeding were not significantly different showing prasugrel to be well-tolerated following PCI especially in patients with acute coronary syndrome.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China
| | - Feng Huang
- Institute of Cardiovascular Diseases and Guangxi Key Laboratory Base of Precision Medicine in Cardio-cerebrovascular Diseases Control and Prevention, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China.
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49
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The relationship between timing of prasugrel pretreatment and in-stent thrombus immediately after percutaneous coronary intervention for acute coronary syndrome: an optical coherence tomography study. Heart Vessels 2018; 33:1159-1167. [PMID: 29691643 DOI: 10.1007/s00380-018-1167-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
Abstract
The optimal timing of pretreatment with prasugrel in percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) is unclear. We used optical coherence tomography (OCT) to compare in-stent thrombus volume immediately after PCI between the administration of low-dose prasugrel (20 mg loading dose) at the time of diagnosis of ACS (early prasugrel: n = 34) and the administration of low-dose prasugrel immediately after diagnostic angiography prior to PCI for ACS (late prasugrel: n = 56). The durations between the administration of prasugrel and OCT in the early prasugrel group and late prasugrel group were 5.1 ± 6.5 and 0.9 ± 0.7 h, respectively (p < 0.001). OCT detected thrombus/plaque protrusion in all stented segments. In-stent thrombus/plaque protrusion volume (2.92 ± 1.96 vs. 6.48 ± 4.97 mm3, p < 0.001), mean in-stent thrombus/plaque protrusion area (0.13 ± 0.07 vs. 0.29 ± 0.23 mm2, p < 0.001) and maximum in-stent thrombus/plaque protrusion area (0.70 ± 0.36 vs. 1.06 ± 0.56 mm2, p < 0.001) were significantly smaller in the early prasugrel group as compared with the late prasugrel group. The administration of prasugrel at the time of diagnosis of ACS was associated with significantly reduced in-stent thrombus/plaque protrusion immediately after PCI as compared with the administration of prasugrel after the coronary angiography prior to PCI.
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Lin TT, Lai HY, Chan KA, Yang YY, Lai CL, Lai MS. Single and dual antiplatelet therapy in elderly patients of medically managed myocardial infarction. BMC Geriatr 2018; 18:86. [PMID: 29621983 PMCID: PMC5887242 DOI: 10.1186/s12877-018-0777-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/28/2018] [Indexed: 11/21/2022] Open
Abstract
Backgrounds To examine the comparative effectiveness between dual and single antiplatelet therapies in real-world, medically managed elderly patients with acute myocardial infarction (AMI). Methods This retrospective study identified very elderly (> 85 years) patients, who were medically managed, with their first AMI from the Taiwan National Health Insurance claims database from 2007 to 2010. Patients were classified as dual antiplatelet therapy (DAPT) group, aspirin only group and clopidogrel only group. Study outcomes included all-cause death, cardiovascular death and gastrointestinal bleeding. Treating DAPT group as the reference, we employed a multivariable Cox regression model to compare the relative risks of outcomes between 3 groups using pairwise comparison approach. Results Among 1469 patients with incident ST-elevation myocardial infarction (STEMI, 14%) or non-STEMI (86%), 390 patients were prescribed DAPT, 549 aspirin only, and 530 clopidogrel only. After 9 months of follow-up, aspirin only group had similar risks of all-cause death (adjusted HR 1.21, 95% CI 0.77–1.89, p = 0.41), cardiovascular death (adjusted HR 1.16, 95% CI 0.66–2.04, p = 0.60) and gastrointestinal bleeding (adjusted HR 1.66, 95% CI 0.77–3.57, p = 0.20) in comparison with DAPT group. Clopidogrel users had a higher risk of all-cause death (adjusted HR 1.50, 95% CI 1.00–2.25, p = 0.049) but similar risks of cardiovascular death and gastrointestinal bleeding when compared with DAPT. Conclusions Among very elderly patients who were medically managed after AMI, single antiplatelet therapy had comparable protective effect as DAPT. But clopidogrel only strategy was associated with a higher risk of all-cause death. Electronic supplementary material The online version of this article (10.1186/s12877-018-0777-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ting-Tse Lin
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan
| | - Hsiu-Yun Lai
- Department of Family Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - K Arnold Chan
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Yun Yang
- Center for Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan. .,Center for critical care medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan. .,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. .,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Mei-Shu Lai
- Center for Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
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