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Manzi L, Florimonte D, Forzano I, Buongiorno F, Sperandeo L, Castiello DS, Paolillo R, Giugliano G, Giacoppo D, Sciahbasi A, Cirillo P, Esposito G, Gargiulo G. Antiplatelet Therapy in Patients Requiring Oral Anticoagulation and Undergoing Percutaneous Coronary Intervention. Interv Cardiol Clin 2024; 13:527-541. [PMID: 39245552 DOI: 10.1016/j.iccl.2024.07.001] [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] [Indexed: 09/10/2024]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is fundamental in all patients undergoing percutaneous coronary intervention (PCI) to prevent coronary thrombosis. In patients with atrial fibrillation (AF), an oral anticoagulant gives protection against ischemic stroke or systemic embolism. AF-PCI patients are at high bleeding risk and decision-making regarding the optimal antithrombotic therapy remains challenging. Dual antithrombotic therapy (DAT) has been shown to reduce bleeding events but at the cost of a higher risk of stent thrombosis. Further studies are needed to clarify the optimal duration of triple antithrombotic therapy (TAT) or DAT and the role of more potent antiplatelet drugs.
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Affiliation(s)
- Lina Manzi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Domenico Florimonte
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Imma Forzano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Federica Buongiorno
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Luca Sperandeo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | | | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Daniele Giacoppo
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy.
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Nappi F. P2Y12 Receptor Inhibitor for Antiaggregant Therapies: From Molecular Pathway to Clinical Application. Int J Mol Sci 2024; 25:7575. [PMID: 39062819 PMCID: PMC11277343 DOI: 10.3390/ijms25147575] [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: 06/09/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
Platelets play a significant role in hemostasis, forming plugs at sites of vascular injury to limit blood loss. However, if platelet activation is not controlled, it can lead to thrombotic events, such as myocardial infarction and stroke. To prevent this, antiplatelet agents are used in clinical settings to limit platelet activation in patients at risk of arterial thrombotic events. However, their use can be associated with a significant risk of bleeding. An enhanced comprehension of platelet signaling mechanisms should facilitate the identification of safer targets for antiplatelet therapy. Over the past decade, our comprehension of the breadth and intricacy of signaling pathways that orchestrate platelet activation has expanded exponentially. Several recent studies have provided further insight into the regulation of platelet signaling events and identified novel targets against which to develop novel antiplatelet agents. Antiplatelet drugs are essential in managing atherothrombotic vascular disease. The current antiplatelet therapy in clinical practice is limited in terms of safety and efficacy. Novel compounds have been developed in response to patient variability and resistance to aspirin and/or clopidogrel. Recent studies based on randomized controlled trials and systematic reviews have definitively demonstrated the role of antiplatelet therapy in reducing the risk of cardiovascular events. Antiplatelet therapy is the recommended course of action for patients with established atherosclerosis. These studies compared monotherapy with a P2Y12 inhibitor versus aspirin for secondary prevention. However, in patients undergoing percutaneous coronary intervention, it is still unclear whether the efficacy of P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy depends on the type of P2Y12 inhibitor. This paper focuses on the advanced-stage evaluation of several promising antiplatelet drugs.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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Laudani C, Capodanno D, Angiolillo DJ. The pharmacology of antiplatelet agents for primary, secondary, and tertiary prevention of ischemic stroke. Expert Opin Pharmacother 2024; 25:1373-1390. [PMID: 39046451 DOI: 10.1080/14656566.2024.2385135] [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: 06/03/2024] [Revised: 07/06/2024] [Accepted: 07/23/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Ischemic etiology accounts for two thirds of all strokes in which platelet activation and aggregation play a major role. A variety of antiplatelet therapies have been tested for primary, secondary, and tertiary prevention, with certain patient subtypes benefiting more than others from a specific regimen. AREAS COVERED This review aims at synthetizing current evidence on pharmacology of antiplatelet agents approved for primary, secondary, and tertiary stroke prevention and their application among possible patient subtypes that may benefit more from their administration. EXPERT OPINION Management of ischemic stroke has largely evolved over the past decades. A better understanding of stroke pathophysiology has allowed to identify patients who can benefit most from antiplatelet therapies, with varying degrees of benefit depending on whether these agents are being used for primary, secondary, or tertiary prevention. Importantly, the antiplatelet treatment regimens currently available have expanded and no longer limited to aspirin but include other drugs such as P2Y12 and phosphodiesterase inhibitors, also used in combination, as well as precision medicine approaches using genetic testing aiming at optimizing the safety and efficacy in this population.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Valgimigli M, Gragnano F, Branca M, Franzone A, da Costa BR, Baber U, Kimura T, Jang Y, Hahn JY, Zhao Q, Windecker S, Gibson CM, Watanabe H, Kim BK, Song YB, Zhu Y, Vranckx P, Mehta S, Ando K, Hong SJ, Gwon HC, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Calabrò P, Jüni P, Mehran R. Ticagrelor or Clopidogrel Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Systematic Review and Patient-Level Meta-Analysis. JAMA Cardiol 2024; 9:437-448. [PMID: 38506796 PMCID: PMC10955340 DOI: 10.1001/jamacardio.2024.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/13/2024] [Indexed: 03/21/2024]
Abstract
Importance Among patients undergoing percutaneous coronary intervention (PCI), it remains unclear whether the treatment efficacy of P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) depends on the type of P2Y12 inhibitor. Objective To assess the risks and benefits of ticagrelor monotherapy or clopidogrel monotherapy compared with standard DAPT after PCI. Data Sources MEDLINE, Embase, TCTMD, and the European Society of Cardiology website were searched from inception to September 10, 2023, without language restriction. Study Selection Included studies were randomized clinical trials comparing P2Y12 inhibitor monotherapy with DAPT on adjudicated end points in patients without indication to oral anticoagulation undergoing PCI. Data Extraction and Synthesis Patient-level data provided by each trial were synthesized into a pooled dataset and analyzed using a 1-step mixed-effects model. The study is reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses of Individual Participant Data. Main Outcomes and Measures The primary objective was to determine noninferiority of ticagrelor or clopidogrel monotherapy vs DAPT on the composite of death, myocardial infarction (MI), or stroke in the per-protocol analysis with a 1.15 margin for the hazard ratio (HR). Key secondary end points were major bleeding and net adverse clinical events (NACE), including the primary end point and major bleeding. Results Analyses included 6 randomized trials including 25 960 patients undergoing PCI, of whom 24 394 patients (12 403 patients receiving DAPT; 8292 patients receiving ticagrelor monotherapy; 3654 patients receiving clopidogrel monotherapy; 45 patients receiving prasugrel monotherapy) were retained in the per-protocol analysis. Trials of ticagrelor monotherapy were conducted in Asia, Europe, and North America; trials of clopidogrel monotherapy were all conducted in Asia. Ticagrelor was noninferior to DAPT for the primary end point (HR, 0.89; 95% CI, 0.74-1.06; P for noninferiority = .004), but clopidogrel was not noninferior (HR, 1.37; 95% CI, 1.01-1.87; P for noninferiority > .99), with this finding driven by noncardiovascular death. The risk of major bleeding was lower with both ticagrelor (HR, 0.47; 95% CI, 0.36-0.62; P < .001) and clopidogrel monotherapy (HR, 0.49; 95% CI, 0.30-0.81; P = .006; P for interaction = 0.88). NACE were lower with ticagrelor (HR, 0.74; 95% CI, 0.64-0.86, P < .001) but not with clopidogrel monotherapy (HR, 1.00; 95% CI, 0.78-1.28; P = .99; P for interaction = .04). Conclusions and Relevance This systematic review and meta-analysis found that ticagrelor monotherapy was noninferior to DAPT for all-cause death, MI, or stroke and superior for major bleeding and NACE. Clopidogrel monotherapy was similarly associated with reduced bleeding but was not noninferior to DAPT for all-cause death, MI, or stroke, largely because of risk observed in 1 trial that exclusively included East Asian patients and a hazard that was driven by an excess of noncardiovascular death.
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Affiliation(s)
- Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Mattia Branca
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno R. da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City
| | - Takeshi Kimura
- Kyoto University Graduate School of Medicine, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Yangsoo Jang
- CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Charles M. Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hirotoshi Watanabe
- Kyoto University Graduate School of Medicine, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, Canada
- Hamilton Health Sciences, Hamilton, Canada
| | - Kenji Ando
- Kokura Memorial Hospital, Department of Cardiology, Kitakyushu, Japan
| | - Sung Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | - Eùgene P. McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | | | - Dik Heg
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
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Capranzano P, Moliterno D, Capodanno D. Aspirin-free antiplatelet strategies after percutaneous coronary interventions. Eur Heart J 2024; 45:572-585. [PMID: 38240716 DOI: 10.1093/eurheartj/ehad876] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/20/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a platelet P2Y12 receptor inhibitor is the standard antithrombotic treatment after percutaneous coronary interventions (PCI). Several trials have challenged guideline-recommended DAPT after PCI by testing the relative clinical effect of an aspirin-free antiplatelet approach-consisting of P2Y12 inhibitor monotherapy after a short course (mostly 1-3 months) of DAPT-among patients undergoing PCI without a concomitant indication for oral anticoagulation (OAC). Overall, these studies have shown P2Y12 inhibitor monotherapy after short DAPT to be associated with a significant reduction in the risk of bleeding without an increase in thrombotic or ischaemic events compared with continued DAPT. Moreover, the effects of the P2Y12 inhibitor monotherapy without prior DAPT or following a very short course of DAPT after PCI are being investigated in emerging studies, of which one has recently reported unfavourable efficacy results associated with the aspirin-free approach compared with conventional DAPT. Finally, P2Y12 inhibitor alone has been compared with aspirin alone as chronic therapy after DAPT discontinuation, thus challenging the historical role of aspirin as a standard of care for secondary prevention following PCI. A thorough understanding of study designs, populations, treatments, results, and limitations of trials testing P2Y12 inhibitor monotherapy vs. DAPT or vs. aspirin is required to consider adopting this treatment in clinical practice. This review addresses the use of aspirin-free antiplatelet strategies among patients undergoing PCI without a concomitant indication for OAC, providing an overview of clinical evidence, guideline indications, practical implications, ongoing issues, and future perspectives.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
| | - David Moliterno
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, The University of Kentucky, Lexington, KY, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
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6
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Gragnano F, Capolongo A, Calabrò P. P2Y 12 Inhibitor or Aspirin Monotherapy in Patients with Coronary Artery Disease: is it Time for a Paradigm Shift? Curr Vasc Pharmacol 2024; 22:1-4. [PMID: 38018206 DOI: 10.2174/0115701611269735231106110250] [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: 07/23/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
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Gragnano F, Cao D, Pirondini L, Franzone A, Kim HS, von Scheidt M, Pettersen AÅR, Zhao Q, Woodward M, Chiarito M, McFadden EP, Park KW, Kastrati A, Seljeflot I, Zhu Y, Windecker S, Kang J, Schunkert H, Arnesen H, Bhatt DL, Steg PG, Calabrò P, Pocock S, Mehran R, Valgimigli M. P2Y 12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events. J Am Coll Cardiol 2023; 82:89-105. [PMID: 37407118 DOI: 10.1016/j.jacc.2023.04.051] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents. OBJECTIVES This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD. METHODS We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis. RESULTS Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (HR: 0.77; 95% CI: 0.66-0.90; P < 0.001). Major bleeding was similar (HR: 0.87; 95% CI: 0.70-1.09; P = 0.23) and net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors. CONCLUSIONS Given its superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Franzone
- Department of Advanced Biomedical Sciences Federico II University of Naples, Naples, Italy
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Alf-Åge R Pettersen
- Department of Cardiology, Ringerike Hospital, Vestre Viken HF, Drammen, Norway; Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Eugene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Kyung Woo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jeehoon Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, INSERM Unité 1148, Paris, France
| | - Paolo Calabrò
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
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8
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Yu Y, Pan D, Bai R, Luo J, Tan Y, Duan W, Shi D. P2y 12 inhibitor monotherapy after 1-3 months dual antiplatelet therapy in patients with coronary artery disease and chronic kidney disease undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197161. [PMID: 37485257 PMCID: PMC10357506 DOI: 10.3389/fcvm.2023.1197161] [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: 03/30/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction In patients with coronary artery disease (CAD) and chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), whether short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitors confers benefits compared with standard DAPT remains unclear. This study aimed to assess the efficacy and safety of 1-3 months of DAPT followed by P2Y12 monotherapy in patients with CAD and CKD undergoing PCI. Methods PubMed, Embase, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) comparing the P2Y12 inhibitor monotherapy after a 1-3 months DAPT vs. DAPT in patients with CAD and CKD after PCI. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, target-vessel revascularization, and stroke. The safety outcome was the major bleeding events, defined as a composite of TIMI major bleeding or Bleeding Academic Research and Consortium (BARC) type 2, 3, or 5 bleeding. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a fixed- or random-effects model depending on the heterogeneity among studies. Results Four RCTs including 20,468 patients (2,833 patients with CKD and 17,635 without CKD) comparing P2Y12 inhibitor monotherapy with DAPT were included in our meta-analysis. Patients with CAD and CKD had higher risk of ischemic and bleeding events. P2Y12 inhibitor monotherapy after 1-3 months of DAPT significantly reduced the risk of major bleeding compared to DAPT in CKD patients (RR: 0.69, 95% CI: 0.51-0.95, P = 0.02) and non-CKD patients (RR: 0.66, 95% CI: 0.49-0.89, P = 0.01). No significant difference regarding MACEs between P2Y12 inhibitor monotherapy and DAPT was found in CKD patients (RR: 0.88, 95% CI: 0.59-1.31, P = 0.53) and non-CKD (RR: 0.91, 95% CI: 0.79-1.04, P = 0.17). Conclusion P2Y12 inhibitor monotherapy after 1-3 months of DAPT was an effective strategy for lowering major bleeding complications without increasing the risk of cardiovascular events in patients with CAD and CKD undergoing PCI as compared with DAPT. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022355228.
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Affiliation(s)
- Yanqiao Yu
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruina Bai
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinwen Luo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Tan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenhui Duan
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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9
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Effectiveness of a structured pharmacist-delivered intervention for patients post-acute coronary syndromes on all-cause hospitalizations and cardiac-related hospital readmissions: a prospective quasi-experimental study. Int J Clin Pharm 2023:10.1007/s11096-023-01538-4. [PMID: 36795303 DOI: 10.1007/s11096-023-01538-4] [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: 09/20/2022] [Accepted: 01/05/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity in Qatar and globally. AIM The primary objective of the study was to evaluate the effectiveness of a structured clinical pharmacist-delivered intervention on all-cause hospitalizations and cardiac-related readmissions in patients with ACS. METHOD A prospective quasi-experimental study was conducted at Heart Hospital in Qatar. Discharged ACS patients were allocated to one of three study arms: (1) an intervention group (received a structured clinical pharmacist-delivered medication reconciliation and counselling at discharge, and two follow-up sessions at 4 weeks and 8 weeks post-discharge), (2) a usual care group (received the general usual care at discharge by clinical pharmacists) or, (3) a control group (discharged during weekends or after clinical pharmacists' working hours). Follow-up sessions for the intervention group were designed to re-educate and counsel patients about their medications, remind them about the importance of medication adherence, and answer any questions they may have. At the hospital, patients were allocated into one of the three groups based on intrinsic and natural allocation procedures. Recruitment of patients took place between March 2016 and December 2017. Data were analyzed based on intention-to-treat principles. RESULTS Three hundred seventy-three patients were enrolled in the study (intervention = 111, usual care = 120, control = 142). Unadjusted results showed that the odds of 6-month all-cause hospitalizations were significantly higher among the usual care (OR 2.034; 95% CI: 1.103-3.748, p = 0.023) and the control arms (OR 2.704; 95% CI: 1.456-5.022, p = 0.002) when compared to the intervention arm. Similarly, patients in the usual care arm (OR 2.304; 95% CI: 1.122-4.730, p = 0.023) and the control arm (OR 3.678; 95% CI: 1.802-7.506, p ≤ 0.001) had greater likelihood of cardiac-related readmissions at 6 months. After adjustment, these reductions were only significant for cardiac-related readmissions between control and intervention groups (OR 2.428; 95% CI: 1.116-5.282, p = 0.025). CONCLUSION This study demonstrated the impact of a structured intervention by clinical pharmacists on cardiac-related readmissions at 6 months post-discharge in patients post-ACS. The impact of the intervention on all-cause hospitalization was not significant after adjustment for potential confounders. Large cost-effective studies are required to determine the sustained impact of structured clinical pharmacist-provided interventions in ACS setting. TRIAL REGISTRATION Clinical Trials: NCT02648243 Registration date: January 7, 2016.
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Escalation and De-Escalation of Antiplatelet Therapy after Acute Coronary Syndrome or PCI: Available Evidence and Implications for Practice. J Clin Med 2022; 11:jcm11216246. [PMID: 36362474 PMCID: PMC9654330 DOI: 10.3390/jcm11216246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 01/25/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard for the antithrombotic management of patients with an acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Implementation of intensified or prolonged DAPT regimens has proven to lower the risk of ischemic events but at the expense of increased bleeding. Importantly, bleeding is a predictor of poor prognosis. Risk stratification and selection of tailored antiplatelet strategies to maximize the net clinical benefit in individual patients with ACS or undergoing PCI is therefore potentially beneficial. Recently, novel approaches including DAPT de-escalation or escalation have been proposed as possible alternatives to standard DAPT. These strategies, which are generally based on patient's risk profile, genetics, and/or platelet function have been proposed to offer more tailored treatments in patients with ACS or PCI, with the ultimate goal of providing adequate ischemic protection while mitigating the risk of bleeding. This review summarizes the available evidence on DAPT de-escalation or escalation (both guided and unguided) and discusses the practical implications of these strategies in the contemporary management of patients with ACS and/or undergoing PCI.
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Opportunità cliniche e impatto sul sistema sanitario di un trattamento ottimale del paziente post-sindrome coronarica acuta. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2022; 9:17-26. [PMID: 36628067 PMCID: PMC9796606 DOI: 10.33393/grhta.2022.2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 01/13/2023] Open
Abstract
Despite the improvement of revascularization procedures, patients with acute coronary syndrome often develop recurrent ischemic events, suggesting a high residual cardiovascular risk in these patients, which requires a strict clinical monitoring as well as an optimal control of modifiable risk factors. To this aim, an optimal management of index event and appropriate preventive measures are equally important. Hospital care by cardiologists should be followed by outpatient management by general practitioners, as established by specific diagnostic and therapeutic pathways, which should warrant an optimal support to the patient. A strict collaboration between hospital and primary care is crucial to monitor and adapt drug therapy after the acute event and improve adherence of the patients to prescribed treatments and implementation of life-style modifications, with benefits also in term of cost-effectiveness. In this context, individualized rehabilitation programs should also be offered to patients with acute coronary syndromes, in order to improve survival and quality of life.
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Shvartsur R, Agam G, Uzzan S, Azab AN. Low-Dose Aspirin Augments the Anti-Inflammatory Effects of Low-Dose Lithium in Lipopolysaccharide-Treated Rats. Pharmaceutics 2022; 14:pharmaceutics14050901. [PMID: 35631487 PMCID: PMC9143757 DOI: 10.3390/pharmaceutics14050901] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 12/23/2022] Open
Abstract
Mounting evidence suggests that immune-system dysfunction and inflammation play a role in the pathophysiology and treatment of mood-disorders in general and of bipolar disorder in particular. The current study examined the effects of chronic low-dose aspirin and low-dose lithium (Li) treatment on plasma and brain interleukin-6 and tumor necrosis factor-α production in lipopolysaccharide (LPS)-treated rats. Rats were fed regular or Li-containing food (0.1%) for six weeks. Low-dose aspirin (1 mg/kg) was administered alone or together with Li. On days 21 and 42 rats were injected with 1 mg/kg LPS or saline. Two h later body temperature was measured and rats were sacrificed. Blood samples, the frontal-cortex, hippocampus, and the hypothalamus were extracted. To assess the therapeutic potential of the combined treatment, rats were administered the same Li + aspirin protocol without LPS. We found that the chronic combined treatment attenuated LPS-induced hypothermia and significantly reduced plasma and brain cytokine level elevation, implicating the potential neuroinflammatory diminution purportedly present among the mentally ill. The combined treatment also significantly decreased immobility time and increased struggling time in the forced swim test, suggestive of an antidepressant-like effect. This preclinical evidence provides a potential approach for treating inflammation-related mental illness.
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Affiliation(s)
- Rachel Shvartsur
- Department of Nursing, School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel;
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel; (G.A.); (S.U.)
| | - Galila Agam
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel; (G.A.); (S.U.)
| | - Sarit Uzzan
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel; (G.A.); (S.U.)
| | - Abed N. Azab
- Department of Nursing, School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel;
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 8410501, Israel; (G.A.); (S.U.)
- Correspondence: ; Tel.: +972-86-479880; Fax: +972-86-477-683
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13
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Han Y, Claessen BE, Chen SL, Chunguang Q, Zhou Y, Xu Y, Hailong L, Chen J, Qiang W, Zhang R, Luo S, Li Y, Zhu J, Zhao X, Cheng X, Wang J, Su X, Tao J, Sun Y, Wang G, Li Y, Bian L, Goel R, Sartori S, Zhang Z, Angiolillo DJ, Cohen DJ, Gibson CM, Kastrati A, Krucoff M, Mehta SR, Ohman EM, Steg PG, Liu Y, Dangas G, Sharma S, Baber U, Mehran R. Ticagrelor With or Without Aspirin in Chinese Patients Undergoing Percutaneous Coronary Intervention: A TWILIGHT China Substudy. Circ Cardiovasc Interv 2022; 15:e009495. [PMID: 35317615 DOI: 10.1161/circinterventions.120.009495] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk/benefit tradeoff of dual antiplatelet therapy after percutaneous coronary intervention may vary in East Asian patients as compared with their non-East Asian counterparts. METHODS The double-blind, placebo-controlled, randomized TWILIGHT trial (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) enrolled patients undergoing high-risk percutaneous coronary intervention. After 3 months of treatment with ticagrelor plus aspirin, event-free and adherent patients remained on ticagrelor and were randomly assigned to receive aspirin or placebo for 1 year. The primary end point was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding; the key secondary end point was the first occurrence of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS Of 9006 enrolled and 7119 randomized patients in TWILIGHT, 1169 patients (13.0%) were enrolled at 27 Chinese sites in this prespecified substudy, of whom 1028 (14.4%) patients were randomized after 3 months. The incidence of the primary end point was 6.2% in the ticagrelor+aspirin group versus 3.5% in the ticagrelor+placebo group between randomization and 1 year (hazard ratio, 0.56 [95% CI, 0.31-0.99]; P=0.048). The key secondary end point occurred in 3.4% of patients in the ticagrelor+aspirin group versus 2.4% in the ticagrelor+placebo group (hazard ratio, 0.70 [95% CI, 0.33-1.46]; P=0.34). There was no interaction between the region of randomization (China versus the rest of the world) and randomized treatment assignment in terms of the primary or key secondary end points. CONCLUSIONS Ticagrelor monotherapy significantly reduced clinically relevant bleeding without increasing ischemic events as compared with ticagrelor plus aspirin in Chinese patients undergoing high-risk percutaneous coronary intervention. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02270242.
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Affiliation(s)
- Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital Jiangsu, China (S.-L.C.)
| | - Qiu Chunguang
- Department of Cardiology' The First Affiliated Hospital of Zhengzhou University, China (Q.C.)
| | - Yujie Zhou
- Department of Cardiology' Beijing Anzhen Hospital Capital Medical University, China (Y.Z.)
| | - Yawei Xu
- Department of Cardiology' Shanghai Tenth Peoples Hospital, China (Y.X.)
| | - Lin Hailong
- Department of Cardiology' Dalian Municipal Central Hospital Affiliated of Dalian Medical University, China (L.H.)
| | - Jiyan Chen
- Department of Cardiology' Guangdong Provincial People's Hospital, Guangzhou, China (J.C.)
| | - Wu Qiang
- Department of Cardiology' Guizhou Provincial People's Hospital, Guiyang, China (W.Q.)
| | - Ruiyan Zhang
- Department of Cardiology' Rui Jin Hospital Shanghai Jiaotong University School of Medicine, Changhai, China (R.Z.)
| | - Suxin Luo
- Department of Cardiology' The First Affiliated Hospital of Chongqing Medical University, China (S.L.)
| | - Yongjun Li
- Department of Cardiology' The Second Hospital of Hebei Medical University (4th Ward), Shijiazhuang, China (Yongjun Li)
| | - Jianhua Zhu
- Department of Cardiology' The First Affiliated Hospital College of Medicine of Zheijang University, Hangzhou, China (J.Z.)
| | - Xianxian Zhao
- Department of Cardiology' Shanghai Changhai Hospital, China (X.Z.)
| | - Xiang Cheng
- Department of Cardiology' Wuhan Union Hospital, China (X.C.)
| | - Jian'an Wang
- Department of Cardiology' The Second Affiliated Hospital of Zhejiang University of Medicine, Hangzhou, China (J.W.)
| | - Xi Su
- Department of Cardiology' WuHan Asia Heart Hospital, China (X.S.)
| | - Jianhong Tao
- Department of Cardiology' Sichuan Provincial People's Hospital, Chengdu, China (J.T.)
| | - Yingxian Sun
- Department of Cardiology' The First Hospital of China Medical University, Shenyang (Y.S.)
| | - Geng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Liya Bian
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - David J Cohen
- Department of Cardiology' University of Missouri-Kansas City (D.J.C.)
| | - C Michael Gibson
- Department of Cardiology' Beth Israel Deaconess Medical Center' Boston' MA (C.M.G.)
| | - Adnan Kastrati
- Department of Cardiology' Deutsches Herzzentrum München, Munich, Germany (A.K.)
| | - Mitchell Krucoff
- Department of Cardiology' Hamilton Health Sciences, Canada (M.K., E.M.O.)
| | - Shamir R Mehta
- Department of Cardiology' Duke University Medical Center, Durham' NC (S.R.M.)
| | - E Magnus Ohman
- Department of Cardiology' Hamilton Health Sciences, Canada (M.K., E.M.O.)
| | - Philippe Gabriel Steg
- Department of Cardiology' Université de Paris, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
| | - Yuqi Liu
- Department of Cardiology, People's Liberation Army General Hospital, Beijing (Y. Liu)
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
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Calderone D, Ingala S, Mauro MS, Angiolillo DJ, Capodanno D. Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events. Expert Rev Cardiovasc Ther 2021; 19:1097-1117. [PMID: 34915778 DOI: 10.1080/14779072.2021.2020100] [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] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Although the role of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) has been disputed, its use in secondary ASCVD prevention is well established. Recent trials of primary prevention do not suggest a significant net benefit with aspirin, whereas accruing evidence supports adopting aspirin-free strategies in the context of potent P2Y12 inhibition for the secondary prevention of selected patients undergoing percutaneous coronary intervention. AREAS COVERED This updated review aims at summarizing and appraising the pharmacological characteristics and the contemporary role of aspirin for the primary and secondary prevention of ASCVD. EXPERT OPINION Recent trials and metanalyses in the context of primary prevention highlighted a modest reduction in ischemic events with aspirin use, counterbalanced by a significant increase in bleeding events. However, ongoing studies on cancer prevention could modify the current paradigm of the unfavorable benefit-risk ratio of aspirin in patients with no overt ASCVD. Conversely, aspirin use is crucial for secondary ASCVD prevention, both in chronic and acute coronary syndromes. Nevertheless, after a brief period of dual antiplatelet therapy, patients at high bleeding risk may benefit from discontinuation of aspirin if a P2Y12 inhibitor is used, hence reducing the bleeding risk with no rebound in thrombotic events.
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Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
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15
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Safety and Efficacy of Combined Low-Dose Lithium and Low-Dose Aspirin: A Pharmacological and Behavioral Proof-of-Concept Study in Rats. Pharmaceutics 2021; 13:pharmaceutics13111827. [PMID: 34834241 PMCID: PMC8619680 DOI: 10.3390/pharmaceutics13111827] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 12/12/2022] Open
Abstract
Despite established efficacy in bipolar disorder patients, lithium (Li) therapy has serious side effects, particularly chronic kidney disease. We examined the safety and behavioral effects of combined chronic low-dose aspirin plus low-dose Li in rats to explore the toxicity and therapeutic potential of this treatment. Rats were fed regular or Li-containing food (0.1% [low-dose, LLD-Li] or 0.2% [standard-dose, STD-Li]) for six weeks. Low-dose aspirin (1 mg/kg) was administered alone or together with Li. Renal function and gastric mucosal integrity were assessed. The effects of the combination treatment were evaluated in depression-like and anxiety-like behavioral models. Co-treatment with aspirin did not alter plasma Li levels. Chronic STD-Li treatment resulted in significant polyuria and polydipsia, elevated blood levels of creatinine and cystatin C, and increased levels of kidney nephrin and podocin—all suggestive of impaired renal function. Aspirin co-treatment significantly damped STD-Li-induced impairments in kidney parameters. There were no gastric ulcers or blood loss in any treatment group. Combined aspirin and LLD-Li resulted in a significant increase in sucrose consumption, and in the time spent in the open arms of an elevated plus-maze compared with the LLD-Li only group, suggestive of antidepressant-like and anxiolytic-like effects, respectively. Thus, we demonstrate that low-dose aspirin mitigated the typical renal side effects of STD-Li dose and enhanced the beneficial behavioral effects of LLD-Li therapy without aggravating its toxicity.
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Calderone D, Greco A, Ingala S, Agnello F, Franchina G, Scalia L, Buccheri S, Capodanno D. Efficacy and Safety of Aspirin for Primary Cardiovascular Risk Prevention in Younger and Older Age: An Updated Systematic Review and Meta-analysis of 178,310 Subjects from 21 Randomized Studies. Thromb Haemost 2021; 122:445-455. [PMID: 34638150 DOI: 10.1055/a-1667-7427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 01/04/2023]
Abstract
AIMS The efficacy and safety of aspirin for primary cardiovascular disease (CVD) prevention is controversial. The aim of this study was to investigate the efficacy and safety of aspirin in subjects with no overt CVD, with a focus on age as a treatment modifier. METHODS AND RESULTS Randomized trials comparing aspirin use versus no aspirin use or placebo were included. The primary efficacy outcome was all-cause death. The primary safety outcome was major bleeding. Secondary ischemic and bleeding outcomes were explored. Subgroup analyses were conducted to investigate the consistency of the effect sizes in studies including younger and older individuals, using a cut-off of 65 years. A total of 21 randomized trials including 173,810 individuals at a mean follow-up of 5.3 years were included. Compared with control, aspirin did not reduce significantly the risk of all-cause death (risk ratio: 0.96; 95% confidence interval: 0.92-1.00, p = 0.057). Major adverse cardiovascular events were significantly reduced by 11%, paralleled by significant reductions in myocardial infarction and transient ischemic attack. Major bleeding, intracranial hemorrhage, and gastrointestinal bleeding were significantly increased by aspirin. There was a significant age interaction for death (p for interaction = 0.007), with aspirin showing a statistically significant 7% relative benefit on all-cause death in studies including younger patients. CONCLUSION The use of aspirin in subjects with no overt CVD was associated with a neutral effect on all-cause death and a modest lower risk of major cardiovascular events at the price of an increased risk in major bleeding. The benefit of aspirin might be more pronounced in younger individuals.
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Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Gabriele Franchina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Sergio Buccheri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
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Valgimigli M, Mehran R, Franzone A, da Costa BR, Baber U, Piccolo R, McFadden EP, Vranckx P, Angiolillo DJ, Leonardi S, Cao D, Dangas GD, Mehta SR, Serruys PW, Gibson CM, Steg GP, Sharma SK, Hamm C, Shlofmitz R, Liebetrau C, Briguori C, Janssens L, Huber K, Ferrario M, Kunadian V, Cohen DJ, Zurakowski A, Oldroyd KG, Yaling H, Dudek D, Sartori S, Kirkham B, Escaned J, Heg D, Windecker S, Pocock S, Jüni P. Ticagrelor Monotherapy Versus Dual-Antiplatelet Therapy After PCI: An Individual Patient-Level Meta-Analysis. JACC Cardiovasc Interv 2021; 14:444-456. [PMID: 33602441 DOI: 10.1016/j.jcin.2020.11.046] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/04/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to compare ticagrelor monotherapy with dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents. BACKGROUND The role of abbreviated DAPT followed by an oral P2Y12 inhibitor after PCI remains uncertain. METHODS Two randomized trials, including 14,628 patients undergoing PCI, comparing ticagrelor monotherapy with standard DAPT on centrally adjudicated endpoints were identified, and individual patient data were analyzed using 1-step fixed-effect models. The protocol was registered in PROSPERO (CRD42019143120). The primary outcomes were the composite of Bleeding Academic Research Consortium type 3 or 5 bleeding tested for superiority and, if met, the composite of all-cause death, myocardial infarction, or stroke at 1 year, tested for noninferiority against a margin of 1.25 on a hazard ratio (HR) scale. RESULTS Bleeding Academic Research Consortium type 3 or 5 bleeding occurred in fewer patients with ticagrelor than DAPT (0.9% vs. 1.7%, respectively; HR: 0.56; 95% confidence interval [CI]: 0.41 to 0.75; p < 0.001). The composite of all-cause death, myocardial infarction, or stroke occurred in 231 patients (3.2%) with ticagrelor and in 254 patients (3.5%) with DAPT (HR: 0.92; 95% CI: 0.76 to 1.10; p < 0.001 for noninferiority). Ticagrelor was associated with lower risk for all-cause (HR: 0.71; 95% CI: 0.52 to 0.96; p = 0.027) and cardiovascular (HR: 0.68; 95% CI: 0.47 to 0.99; p = 0.044) mortality. Rates of myocardial infarction (2.01% vs. 2.05%; p = 0.88), stent thrombosis (0.29% vs. 0.38%; p = 0.32), and stroke (0.47% vs. 0.36%; p = 0.30) were similar. CONCLUSIONS Ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without a concomitant increase in ischemic events.
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Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno R da Costa
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Davide Cao
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gabriel P Steg
- Université de Paris and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Samin K Sharma
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Hamm
- German Center for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Richard Shlofmitz
- Department of Cardiology, St. Francis Hospital, Roslyn, New York, USA
| | - Christoph Liebetrau
- German Center for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | | | | | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University Medical School, Vienna, Austria
| | - Maurizio Ferrario
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David J Cohen
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Aleksander Zurakowski
- Department of Interventional Cardiology Chrzanów, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Keith G Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Han Yaling
- General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Dariuz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Kirkham
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - Dik Heg
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Gargiulo G, Esposito G. Aspirin Monotherapy After BioFreedom Stent and 1-Month DAPT: Is Less More Even in Low-Risk Patients? JACC Cardiovasc Interv 2021; 14:1812-1814. [PMID: 34332942 DOI: 10.1016/j.jcin.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
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19
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Sharma G, Feldman DI, Bittl JA. Moving Toward Ticagrelor Monotherapy: Like Boats Against the Current. JACC Cardiovasc Interv 2021; 14:1447-1449. [PMID: 34238554 DOI: 10.1016/j.jcin.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Garima Sharma
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - David I Feldman
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Liang XY, Li Y, Qiao X, Zhang WJ, Wang ZL. Clinical Outcomes of Very Short Term Dual Antiplatelet Therapy in Patients With or Without Diabetes Undergoing Second-Generation Drug-Eluting Stents: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Front Cardiovasc Med 2021; 8:655718. [PMID: 34277725 PMCID: PMC8281288 DOI: 10.3389/fcvm.2021.655718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with diabetes represent 20-30% of the population considered for percutaneous coronary intervention (PCI) and associate with more deleterious clinical outcome, which requires the optimal strategy of dual antiplatelet therapy (DAPT). The meta-analysis aims to compare clinical outcomes between very short (1-3 months) and standard (12 months) DAPT after implanting the second-generation drug-eluting stents in patients with or without diabetes following PCI. Methods and Analysis: PubMed, Embase, Web of Science, Ovid, Cochrane Library, and ClinicalTrials.gov were searched for studies comparing the very short term and standard DAPT in patients with or without diabetes following PCI. Risk ratio with 95% confidence intervals was used to evaluate the pooled effect of discontinuous variables, and the pooled analyses were performed with RevMan 5.3 and Stata SE 14.0 software. Results: A total of 38,864 patients were randomized to the very short term DAPT (N = 19,423) vs. standard DAPT (N = 19,441). Among them, 11,476 patients were diabetes and 27,388 patients were non-diabetes. The primary outcome of the net adverse clinical event (NACE) was significantly lower in diabetic patients with very short term DAPT (risk ratio 0.72, 95% CI 0.60-0.88, p = 0.0009). The same result was also found in the major cardiac or cerebrovascular events (MACCEs) (0.87, 0.78-0.98, p = 0.03). The risk of major or minor bleeding was significantly reduced in very short term DAPT regardless of the diabetes statue (0.69, 0.52-0.93, p = 0.01 in the diabetic group, and 0.50, 0.39-0.63, p <0.0001 in the non-diabetic group). There was no statistical difference in the incidence of major bleeding, all-cause death, cardiac death, myocardial infarction, definite or probable stent thrombosis, and stroke between the very short term DAPT (1-3 months) and standard DAPT (12 months) in patients with or without diabetes. Conclusion: The very short term DAPT can significantly reduce the risk of the NACE and MACCE in patients with diabetes compared to standard DAPT. Meanwhile, the very short term DAPT can also reduce the incidence of major and minor bleeding without increasing the risk of ischemia in patients with or without diabetes (Registered by PROSPERO, CRD42020192133). Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, Identifier: CRD42020192133.
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Affiliation(s)
- Xi-Ying Liang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yan Li
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Xuan Qiao
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Wen-Jiao Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Zhi-Lu Wang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
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21
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Valgimigli M, Gragnano F, Branca M, Franzone A, Baber U, Jang Y, Kimura T, Hahn JY, Zhao Q, Windecker S, Gibson CM, Kim BK, Watanabe H, Song YB, Zhu Y, Vranckx P, Mehta S, Hong SJ, Ando K, Gwon HC, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Jüni P, Mehran R. P2Y12 inhibitor monotherapy or dual antiplatelet therapy after coronary revascularisation: individual patient level meta-analysis of randomised controlled trials. BMJ 2021; 373:n1332. [PMID: 34135011 PMCID: PMC8207247 DOI: 10.1136/bmj.n1332] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the risks and benefits of P2Y12 inhibitor monotherapy compared with dual antiplatelet therapy (DAPT) and whether these associations are modified by patients' characteristics. DESIGN Individual patient level meta-analysis of randomised controlled trials. DATA SOURCES Searches were conducted in Ovid Medline, Embase, and three websites (www.tctmd.com, www.escardio.org, www.acc.org/cardiosourceplus) from inception to 16 July 2020. The primary authors provided individual participant data. ELIGIBILITY CRITERIA Randomised controlled trials comparing effects of oral P2Y12 monotherapy and DAPT on centrally adjudicated endpoints after coronary revascularisation in patients without an indication for oral anticoagulation. MAIN OUTCOME MEASURES The primary outcome was a composite of all cause death, myocardial infarction, and stroke, tested for non-inferiority against a margin of 1.15 for the hazard ratio. The key safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or type 5 bleeding. RESULTS The meta-analysis included data from six trials, including 24 096 patients. The primary outcome occurred in 283 (2.95%) patients with P2Y12 inhibitor monotherapy and 315 (3.27%) with DAPT in the per protocol population (hazard ratio 0.93, 95% confidence interval 0.79 to 1.09; P=0.005 for non-inferiority; P=0.38 for superiority; τ2=0.00) and in 303 (2.94%) with P2Y12 inhibitor monotherapy and 338 (3.36%) with DAPT in the intention to treat population (0.90, 0.77 to 1.05; P=0.18 for superiority; τ2=0.00). The treatment effect was consistent across all subgroups, except for sex (P for interaction=0.02), suggesting that P2Y12 inhibitor monotherapy lowers the risk of the primary ischaemic endpoint in women (hazard ratio 0.64, 0.46 to 0.89) but not in men (1.00, 0.83 to 1.19). The risk of bleeding was lower with P2Y12 inhibitor monotherapy than with DAPT (97 (0.89%) v 197 (1.83%); hazard ratio 0.49, 0.39 to 0.63; P<0.001; τ2=0.03), which was consistent across subgroups, except for type of P2Y12 inhibitor (P for interaction=0.02), suggesting greater benefit when a newer P2Y12 inhibitor rather than clopidogrel was part of the DAPT regimen. CONCLUSIONS P2Y12 inhibitor monotherapy was associated with a similar risk of death, myocardial infarction, or stroke, with evidence that this association may be modified by sex, and a lower bleeding risk compared with DAPT. REGISTRATION PROSPERO CRD42020176853.
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Affiliation(s)
- Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- Contributed equally
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
- Contributed equally
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Charles M Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenji Ando
- Kokura Memorial Hospital, Department of Cardiology, Kitakyushu, Japan
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, Netherlands
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dik Heg
- Clinical Trials Unit, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Contributed equally
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Contributed equally
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22
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Giacoppo D, Matsuda Y, Fovino LN, D'Amico G, Gargiulo G, Byrne RA, Capodanno D, Valgimigli M, Mehran R, Tarantini G. Short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy vs. prolonged dual antiplatelet therapy after percutaneous coronary intervention with second-generation drug-eluting stents: a systematic review and meta-analysis of randomized clinical trials. Eur Heart J 2021; 42:308-319. [PMID: 33284979 DOI: 10.1093/eurheartj/ehaa739] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/26/2020] [Accepted: 09/04/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS After percutaneous coronary intervention (PCI) with second-generation drug-eluting stent (DES), whether short dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) with a P2Y12 receptor inhibitor confers benefits compared with prolonged DAPT is unclear. METHODS AND RESULTS Multiple electronic databases, including PubMed, Scopus, Web of Sciences, Ovid, and ScienceDirect, were searched to identify randomized clinical trials comparing ≤3 months of DAPT followed by P2Y12 inhibitor SAPT vs. 12 months of DAPT after PCI with second-generation DES implantation. The primary and co-primary outcomes of interest were major bleeding and stent thrombosis 1 year after randomization. Summary hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by fixed-effect and random-effects models. Multiple sensitivity analyses including random-effects models 95% CI adjustment were applied. A sensitivity analysis comparing trials using P2Y12 inhibitor SAPT with those using aspirin SAPT was performed. A total of five randomized clinical trials (32 145 patients) were available. Major bleeding was significantly lower in the patients assigned to short DAPT followed by P2Y12 inhibitor SAPT compared with those assigned to 12-month DAPT (random-effects model: HR 0.63, 95% 0.45-0.86). No significant differences between groups were observed in terms of stent thrombosis (random-effects model: HR 1.19, 95% CI 0.86-1.65) and the secondary endpoints of all-cause death (random-effects model: HR 0.85, 95% CI 0.70-1.03), myocardial infarction (random-effects model: HR 1.05, 95% CI 0.89-1.23), and stroke (random-effects model: HR 1.08, 95% CI 0.68-1.74). Sensitivity analyses showed overall consistent results. By comparing trials testing ≤3 months of DAPT followed by P2Y12 inhibitor SAPT vs. 12 months of DAPT with trials testing ≤3 months of DAPT followed by aspirin SAPT vs. 12-month of DAPT, there was no treatment-by-subgroup interaction for each endpoint. By combining all these trials, regardless of the type of SAPT, short DAPT was associated with lower major bleeding (random-effects model: HR 0.63, 95% CI 0.48-0.83) and no differences in stent thrombosis, all-cause death, myocardial infarction, and stroke were observed between regimens. CONCLUSION After second-generation DES implantation, 1-3 months of DAPT followed by P2Y12 inhibitor SAPT is associated with lower major bleeding and similar stent thrombosis, all-cause death, myocardial infarction, and stroke compared with prolonged DAPT. Whether P2Y12 inhibitor SAPT is preferable to aspirin SAPT needs further investigation.
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Affiliation(s)
- Daniele Giacoppo
- Department of Cardiac-Thoracic-Vascular Sciences, University of Padova, Via Giustiniani 2, 35128 Padua, Italy.,Department of Cardiology, ISAResearch, German Heart Center, Lazarettstrasse 36, 80636 Munich, Germany.,Cardiovascular Research Institute, Mater Private Hospital, Eccles Street 73, Dublin 7, D07 WKW8, Ireland
| | - Yuji Matsuda
- Department of Cardiac-Thoracic-Vascular Sciences, University of Padova, Via Giustiniani 2, 35128 Padua, Italy.,Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Luca Nai Fovino
- Department of Cardiac-Thoracic-Vascular Sciences, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Gianpiero D'Amico
- Department of Cardiac-Thoracic-Vascular Sciences, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Pansini 5, 80131 Naples, Italy
| | - Robert A Byrne
- Cardiovascular Research Institute, Mater Private Hospital, Eccles Street 73, Dublin 7, D07 WKW8, Ireland.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Saint Peter's, Dublin 2, D02 YN77, Ireland
| | - Davide Capodanno
- Department of Cardiology, Policlinico "Rodolico-San Marco", University of Catania, Via S. Sofia 78, 95125 Catania, Italy
| | - Marco Valgimigli
- Department of Cardiology, Inselspital Bern, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.,Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Giuseppe Tarantini
- Department of Cardiac-Thoracic-Vascular Sciences, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
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23
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Liberale L, Montecucco F, Tardif JC, Libby P, Camici GG. Inflamm-ageing: the role of inflammation in age-dependent cardiovascular disease. Eur Heart J 2021; 41:2974-2982. [PMID: 32006431 DOI: 10.1093/eurheartj/ehz961] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/10/2019] [Accepted: 01/09/2020] [Indexed: 12/12/2022] Open
Abstract
The ongoing worldwide increase in life expectancy portends a rising prevalence of age-related cardiovascular (CV) diseases in the coming decades that demands a deeper understanding of their molecular mechanisms. Inflammation has recently emerged as an important contributor for CV disease development. Indeed, a state of chronic sterile low-grade inflammation characterizes older organisms (also known as inflamm-ageing) and participates pivotally in the development of frailty, disability, and most chronic degenerative diseases including age-related CV and cerebrovascular afflictions. Due to chronic activation of inflammasomes and to reduced endogenous anti-inflammatory mechanisms, inflamm-ageing contributes to the activation of leucocytes, endothelial, and vascular smooth muscle cells, thus accelerating vascular ageing and atherosclerosis. Furthermore, inflamm-ageing promotes the development of catastrophic athero-thrombotic complications by enhancing platelet reactivity and predisposing to plaque rupture and erosion. Thus, inflamm-ageing and its contributors or molecular mediators might furnish targets for novel therapeutic strategies that could promote healthy ageing and conserve resources for health care systems worldwide. Here, we discuss recent findings in the pathophysiology of inflamm-ageing, the impact of these processes on the development of age-related CV diseases, results from clinical trials targeting its components and the potential implementation of these advances into daily clinical practice.
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Affiliation(s)
- Luca Liberale
- Center for Molecular Cardiology, University of Zürich, Wagistrasse 12, Schlieren CH-8952, Switzerland.,Department of Internal Medicine, First Clinic of Internal Medicine, University of Genoa, v.le Benedetto XV 10, 16132 Genoa, Italy
| | - Fabrizio Montecucco
- IRCCS Ospedale Policlinico San Martino Genoa - Italian Cardiovascular Network, L.go Rosanna Benzi 10, 16132 Genoa, Italy.,First Clinic of Internal Medicine, Department of Internal Medicine and Centre of Excellence for Biomedical Research (CEBR), University of Genoa, v.le Benedetto XV 10, 16132 Genoa, Italy
| | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montreal, Rue Bélanger 5000, Montreal, QC H1T 1C8, Canada
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Francis Street 75, Boston, MA 02115, USA
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Wagistrasse 12, Schlieren CH-8952, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.,Department of Research and Education, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
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24
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Ho MY, Chen PW, Feng WH, Su CH, Huang SW, Cheng CW, Yeh HI, Chen CP, Huang WC, Fang CC, Lin HW, Lin SH, Hsieh IC, Li YH. Effect of aspirin treatment duration on clinical outcomes in acute coronary syndrome patients with early aspirin discontinuation and received P2Y12 inhibitor monotherapy. PLoS One 2021; 16:e0251109. [PMID: 33979377 PMCID: PMC8115803 DOI: 10.1371/journal.pone.0251109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022] Open
Abstract
Recent clinical trials showed that short aspirin duration (1 or 3 months) in dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy reduced the risk of bleeding and did not increase the ischemic risk compared to 12-month DAPT in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). However, it is unclear about the optimal duration of aspirin in P2Y12 inhibitor monotherapy. The purpose of this study was to evaluate the influence of aspirin treatment duration on clinical outcomes in a cohort of ACS patients with early aspirin interruption and received P2Y12 inhibitor monotherapy. From January 1, 2014 to December 31, 2018, we included 498 ACS patients (age 70.18 ± 12.84 years, 71.3% men) with aspirin stopped for various reasons before 6 months after PCI and received P2Y12 inhibitor monotherapy. The clinical outcomes between those with aspirin treatment ≤ 1 month and > 1 month were compared in 12-month follow up after PCI. Inverse probability of treatment weighting was used to balance the covariates between groups. The mean duration of aspirin treatment was 7.52 ± 8.10 days vs. 98.05 ± 56.70 days in the 2 groups (p<0.001). The primary composite endpoint of all-cause mortality, recurrent ACS or unplanned revascularization and stroke occurred in 12.6% and 14.4% in the 2 groups (adjusted HR 1.19, 95% CI 0.85-1.68). The safety outcome of BARC 3 or 5 bleeding was also similar (adjusted HR 0.69, 95% CI 0.34-1.40) between the 2 groups. In conclusion, patients with ≤ 1 month aspirin treatment had similar clinical outcomes to those with treatment > 1 month. Our results indicated that ≤ 1-month aspirin may be enough in P2Y12 inhibitor monotherapy strategy for ACS patients undergoing PCI.
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Affiliation(s)
- Ming-Yun Ho
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Po-Wei Chen
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Han Feng
- Kaohsiung Municipal Ta-Tung Hospital and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chun-Hung Su
- Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung, Taiwan
| | - Sheng-Wei Huang
- Chung Shan Medical University Hospital and Chung Shan Medical University, Taichung, Taiwan
| | | | - Hung-I Yeh
- MacKay Memorial Hospital, Taipei, Taiwan
| | | | - Wei-Chun Huang
- Kaohsiung Veterans General Hospital, Fooyin University, Kaohsiung and National Yang Ming University, Taipei, Taiwan
| | | | - Hui-Wen Lin
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Chang Hsieh
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail: (YHL); (ICH)
| | - Yi-Heng Li
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail: (YHL); (ICH)
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25
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Patrono C, Rocca B. Aspirin at 120: Retiring, recombining, or repurposing? Res Pract Thromb Haemost 2021; 5:e12516. [PMID: 34095732 PMCID: PMC8162399 DOI: 10.1002/rth2.12516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/24/2021] [Accepted: 03/14/2021] [Indexed: 12/12/2022] Open
Abstract
During the past 20 years, we have witnessed the following trends in aspirin usage: (i) a "dropping" trend, characterized by the early discontinuation of low-dose aspirin from dual antiplatelet therapy or triple antithrombotic therapy (oral anticoagulation plus dual antiplatelet therapy in patients with atrial fibrillation) following an acute coronary syndrome or after percutaneous coronary intervention; (ii) a "combinatorial" trend, featuring the addition of a lower dose of a P2Y12 inhibitor or direct oral anticoagulant drug to low-dose aspirin for the long-term treatment of stable patients with atherosclerotic cardiovascular disease; and (iii) a "repurposing" trend, characterized by growing interest in the oncologic community to assess the chemopreventive effect of aspirin against certain types of cancers (particularly of the gastrointestinal tract), both as primary prevention and adjuvant therapy. The aim of this review is to present the mechanistic rationale underlying these trends, discuss the design and findings of trials testing novel treatments or new therapeutic applications of aspirin, and report on the ISTH Congress results on this topic.
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Affiliation(s)
- Carlo Patrono
- Department of SafetySection of PharmacologyCatholic University School of MedicineRomeItaly
| | - Bianca Rocca
- Department of SafetySection of PharmacologyCatholic University School of MedicineRomeItaly
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Evolution of Clinical Thinking and Practice Regarding Aspirin: What Has Changed and Why? Am J Cardiol 2021; 144 Suppl 1:S10-S14. [PMID: 33706984 DOI: 10.1016/j.amjcard.2020.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/11/2020] [Indexed: 01/15/2023]
Abstract
Aspirin (ASA) is the original antiplatelet agent. Its routine use, long unquestioned for both primary and secondary prevention in cardiovascular disease, is under increasing scrutiny as the risk:benefit balance for ASA becomes less clear and other disease- and risk-modifying approaches are validated. It can be viewed as a significant advance in evidence-based medicine that the use of an inexpensive, readily available, long-validated therapy is being questioned in large, rigorous trials. In this overview we present the important questions surrounding a more informed approach to ASA therapy: duration of therapy, assessment of net clinical benefit, and timing of start and stop strategies. We also consider potential explanations for "breakthrough" thrombosis when patients are on ASA therapy. Other manuscripts in this Supplement address the specifics of primary prevention, secondary prevention, triple oral antithrombotic therapy, and the future of ASA in cardiovascular medicine.
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Dotto C, Lombarte Serrat A, Ledesma M, Vay C, Ehling-Schulz M, Sordelli DO, Grunert T, Buzzola F. Salicylic acid stabilizes Staphylococcus aureus biofilm by impairing the agr quorum-sensing system. Sci Rep 2021; 11:2953. [PMID: 33536503 PMCID: PMC7858585 DOI: 10.1038/s41598-021-82308-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/19/2021] [Indexed: 01/30/2023] Open
Abstract
Salicylic acid (SAL) has recently been shown to induce biofilm formation in Staphylococcus aureus and to affect the expression of virulence factors. This study was aimed to investigate the effect of SAL on the regulatory agr system and its impact on S. aureus biofilm formation. The agr quorum-sensing system, which is a central regulator in S. aureus pathogenicity, plays a pivotal role in the dispersal of S. aureus mature biofilms and contributes to the creation of new colonization sites. Here, we demonstrate that SAL impairs biofilm dispersal by interfering with agr expression. As revealed by our work, protease and surfactant molecule production is diminished, and bacterial cell autolysis is also negatively affected by SAL. Furthermore, as a consequence of SAL treatment, the S. aureus biofilm matrix revealed the lack of extracellular DNA. In silico docking and simulation of molecular dynamics provided evidence for a potential interaction of AgrA and SAL, resulting in reduced activity of the agr system. In conclusion, SAL stabilized the mature S. aureus biofilms, which may prevent bacterial cell dissemination. However, it may foster the establishment of infections locally and consequently increase bacterial persistence leading to therapeutic failure.
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Affiliation(s)
- Cristian Dotto
- Instituto de Investigaciones en Microbiología y Parasitología Médica (IMPaM), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres" (INGEBI), CONICET, Buenos Aires, Argentina
| | - Andrea Lombarte Serrat
- Instituto de Investigaciones en Microbiología y Parasitología Médica (IMPaM), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Martín Ledesma
- Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Facultad de Farmacia y Bioquímica, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Vay
- Instituto de Fisiopatología y Bioquímica Clínica (INFIBIOC), Facultad de Farmacia y Bioquímica, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Monika Ehling-Schulz
- Functional Microbiology, Institute of Microbiology, Department of Pathobiology, University of Veterinary Medicine, Vienna, Austria
| | - Daniel O Sordelli
- Instituto de Investigaciones en Microbiología y Parasitología Médica (IMPaM), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad de Buenos Aires, Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Tom Grunert
- Functional Microbiology, Institute of Microbiology, Department of Pathobiology, University of Veterinary Medicine, Vienna, Austria
| | - Fernanda Buzzola
- Instituto de Investigaciones en Microbiología y Parasitología Médica (IMPaM), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Universidad de Buenos Aires, Buenos Aires, Argentina.
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.
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Kawashima H, Tomaniak M, Ono M, Wang R, Hara H, Gao C, Takahashi K, Sharif F, Thury A, Suryapranata H, Walsh S, Cotton J, Carrie D, Sabate M, Steinwender C, Leibundgut G, Wykrzykowska J, de Winter RJ, Garg S, Hamm C, Steg PG, Jüni P, Vranckx P, Valgimigli M, Windecker S, Onuma Y, Serruys PW. Safety and Efficacy of 1-Month Dual Antiplatelet Therapy (Ticagrelor + Aspirin) Followed by 23-Month Ticagrelor Monotherapy in Patients Undergoing Staged Percutaneous Coronary Intervention (A Sub-Study from GLOBAL LEADERS). Am J Cardiol 2021; 138:1-10. [PMID: 33065080 DOI: 10.1016/j.amjcard.2020.09.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 12/18/2022]
Abstract
Patients undergoing staged percutaneous coronary intervention (SPCI) are exposed to extended duration of antiplatelet therapy, and a novel aspirin-free antiplatelet regimen after SPCI should be specifically evaluated among these patients. This is a prespecified substudy of the GLOBAL LEADERS which is a randomized, open-label trial, comparing an experimental regimen of 1-month dual antiplatelet therapy (DAPT; ticagrelor and aspirin) followed by 23-month ticagrelor monotherapy to a reference regimen of 12-month DAPT followed by 12-month aspirin monotherapy. Patients were stratified according to whether or not SPCI was performed. The impact of the timing of SPCI on clinical outcomes was also investigated. Of 15,968 randomized patients, 1,651 patients underwent SPCI within 3 months. These patients with SPCI had a significantly higher risk of bleeding and ischemic endpoints than those without SPCI. In patients undergoing SPCI, the primary endpoint (composite of all-cause death or new Q-wave myocardial infarction at 2 years) and secondary safety endpoint (Bleeding Academic Research Consortium [BARC]-defined bleeding 3 or 5) were similar in the 2 regimens. However, in patients presenting with acute coronary syndrome (ACS), the experimental regimen reduced a risk of BARC 3 or 5 bleeding (1.8% vs 4.5%; HR 0.387; 95% CI 0.179 to 0.836; p = 0.016). In patients undergoing SPCI later than 10 days after index procedure, this risk reduction was still prominent (0.8% vs 2.3%; HR 0.321; 95% CI 0.116 to 0.891; p = 0.029). In conclusion, patients undergoing SPCI are at high risk and may need special attention from clinicians. In ACS patients undergoing SPCI, a novel aspirin-free antiplatelet regimen appears to be associated with a lower bleeding risk than with standard DAPT.
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Johnson TW, Baos S, Collett L, Hutchinson JL, Nkau M, Molina M, Aungraheeta R, Reilly‐Stitt C, Bowles R, Reeves BC, Rogers CA, Mundell SJ, Baumbach A, Mumford AD. Pharmacodynamic Comparison of Ticagrelor Monotherapy Versus Ticagrelor and Aspirin in Patients After Percutaneous Coronary Intervention: The TEMPLATE (Ticagrelor Monotherapy and Platelet Reactivity) Randomized Controlled Trial. J Am Heart Assoc 2020; 9:e016495. [PMID: 33305660 PMCID: PMC7955396 DOI: 10.1161/jaha.120.016495] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background To assess differences in platelet inhibition during ticagrelor monotherapy (TIC) or dual therapy with ticagrelor and aspirin (TIC+ASP) in patients after percutaneous coronary intervention using a comprehensive panel of functional tests. Methods and Results In a single‐center parallel group, open label, randomized controlled trial, 110 participants were randomized to receive either TIC (n=55) or TIC+ASP (n=55) for 4 weeks. The primary outcome was the platelet aggregation response with 10 μmol/L thrombin receptor activation peptide‐6 (TRAP‐6). The secondary outcomes were platelet aggregation responses and binding of surface activation markers with a panel of other activators. The mean percentage aggregation for 10 μmol/L TRAP‐6 was similar for the TIC and TIC+ASP groups (mean difference+4.29; 95% CI, −0.87 to +9.46). Aggregation was higher in the TIC group compared with the TIC+ASP group with 1 μg/mL (+6.47; +2.04 to +10.90) and 0.5 μg/mL (+14.00; +7.63 to +20.39) collagen related peptide. Aggregation responses with 5 μmol/L TRAP‐6, 5 μmol/L or 2.5 μmol/L thromboxane A2 receptor agonist and surface activation marker binding with 5 μmol/L TRAP‐6 or 0.5 μg/mL collagen related peptide were the same between the treatment groups. Conclusions Patients with PCI show similar levels of inhibition of most platelet activation pathways with TIC compared with dual therapy with TIC + ASP. However, the greater aggregation response with collagen related peptide during TIC indicates incomplete inhibition of glycoprotein VI (collagen) receptor‐mediated platelet activation. This difference in pharmacodynamic response to anti‐platelet medication may contribute to the lower bleeding rates observed with TIC compared with dual antiplatelet therapy in recent clinical trials. Registration Information URL: https://www.isrctn.com; Unique Identifier ISRCTN84335288.
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Affiliation(s)
- Thomas W. Johnson
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Sarah Baos
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Laura Collett
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - James L. Hutchinson
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | - Martin Nkau
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Maria Molina
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Riyaad Aungraheeta
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | | | - Ruth Bowles
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Barnaby C. Reeves
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Chris A. Rogers
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Stuart J Mundell
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | - Andreas Baumbach
- William Harvey Research InstituteQueen Mary University of LondonLondonUK
| | - Andrew D. Mumford
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
- School of Cellular and Molecular MedicineUniversity of BristolBristolUK
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Fabris E, Sinagra G, Valgimigli M. Antithrombotic therapy in heart failure and sinus rhythm: the ongoing search for a better match of patients to therapy. Eur J Heart Fail 2020; 23:657-660. [PMID: 33131202 DOI: 10.1002/ejhf.2045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | | | - Marco Valgimigli
- CardioCentro Ticino, Lugano and University of Bern, Bern, Switzerland
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31
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Relation of High Lipoprotein (a) Concentrations to Platelet Reactivity in Individuals with and Without Coronary Artery Disease. Adv Ther 2020; 37:4568-4584. [PMID: 32889667 PMCID: PMC7547998 DOI: 10.1007/s12325-020-01483-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Lipoprotein (a) [Lp(a)] is a risk factor for coronary artery disease (CAD). To the best of our knowledge, this is the first study addressing the relationship between Lp(a) and platelet reactivity in primary and secondary prevention. METHODS Lp(a) was evaluated in 396 individuals with (82.3%) and without (17.7%) obstructive CAD. The population was divided into two groups according to Lp(a) concentrations with a cutoff value of 50 mg/dL. The primary objective was to evaluate the association between Lp(a) and adenosine diphosphate (ADP)-induced platelet reactivity using the VerifyNow™ P2Y12 assay. Platelet reactivity was also induced by arachidonic acid and collagen-epinephrine (C-EPI) and assessed by Multiplate™, platelet function analyzer™ 100 (PFA-100), and light transmission aggregometry (LTA) assays. Secondary objectives included the assessment of the primary endpoint in individuals with or without CAD. RESULTS Overall, 294 (74.2%) individuals had Lp(a) < 50 mg/dL [median (IQR) 13.2 (5.8-27.9) mg/dL] and 102 (25.8%) had Lp(a) ≥ 50 mg/dL [82.5 (67.6-114.5) mg/dL], P < 0.001. Univariate analysis in the entire population revealed no differences in ADP-induced platelet reactivity between individuals with Lp(a) ≥ 50 mg/dL (249.4 ± 43.8 PRU) versus Lp(a) < 50 mg/dL (243.1 ± 52.2 PRU), P = 0.277. Similar findings were present in individuals with (P = 0.228) and without (P = 0.669) CAD, and regardless of the agonist used or method of analysis (all P > 0.05). Finally, multivariable analysis did not show a significant association between ADP-induced platelet reactivity and Lp(a) ≥ 50 mg/dL [adjusted OR = 1.00 [(95% CI 0.99-1.01), P = 0.590]. CONCLUSION In individuals with or without CAD, Lp(a) ≥ 50 mg/dL was not associated with higher platelet reactivity.
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32
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Gargiulo G, Cannon CP, Gibson CM, Goette A, Lopes RD, Oldgren J, Korjian S, Windecker S, Esposito G, Vranckx P, Valgimigli M. Safety and efficacy of double vs. triple antithrombotic therapy in patients with atrial fibrillation with or without acute coronary syndrome undergoing percutaneous coronary intervention: a collaborative meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f50-f60. [PMID: 33119069 PMCID: PMC8117456 DOI: 10.1093/ehjcvp/pvaa116] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/10/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
Aims Safety and efficacy of antithrombotic regimens in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) may differ based on clinical presentation. We sought to compare double vs. triple antithrombotic therapy (DAT vs. TAT) in AF patients with or without acute coronary syndrome (ACS) undergoing PCI. Methods and results A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials. Data on subgroups of ACS or elective PCI were obtained by published reports or trial investigators. A total of 10 193 patients from four NOAC trials were analysed, of whom 5675 presenting with ACS (DAT = 3063 vs. TAT = 2612) and 4518 with stable coronary artery disease (SCAD; DAT = 2421 vs. TAT = 2097). The primary safety endpoint of ISTH major bleeding or clinically relevant non-major bleeding was reduced with DAT compared with TAT in both ACS (12.2% vs. 19.4%; RR 0.63, 95% CI 0.56–0.71; P < 0.0001; I2 = 0%) and SCAD (14.6% vs. 22.0%; RR 0.68, 95% CI 0.55–0.85; P = 0.0008; I2 = 66%), without interaction (P-int = 0.54). Findings were consistent for secondary bleeding endpoints, including intra-cranial haemorrhage. In both subgroups, there was no difference between DAT and TAT for all-cause death, major adverse cardiovascular events, or stroke. Myocardial infarction and stent thrombosis were numerically higher with DAT vs. TAT consistently in ACS and SCAD (P-int = 0.60 and 0.86, respectively). Findings were confirmed by multiple sensitivity analyses, including a separate analysis on dabigatran regimens and a restriction to PCI population. Conclusions DAT, compared with TAT, is associated with lower bleeding risks, including intra-cranial haemorrhage, and a small non-significant excess of cardiac ischaemic events in both patients with or without ACS.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Heart and Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Baim Institute for Clinical Research, 930-W Commonwealth Avenue, Boston, MA 02215, USA
| | - Charles Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andreas Goette
- St. Vincenz-Hospital, Am Busdorf 2, 33098 Paderborn, Germany.,Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany.,Atrial Fibrillation Network (AFNET), Mendel Str.11, 48149 Münster, Germany
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, Durham, NC 27701, USA
| | - Jonas Oldgren
- Uppsala Clinical Research Center and, Department of Medical Sciences, Uppsala University, Dag Hammarskjolds vag 38, SE-751 85 Uppsala, Sweden
| | - Serge Korjian
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3030 Bern, Switzerland
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences, Hasselt University, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3030 Bern, Switzerland
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Gargiulo G, Goette A, Tijssen J, Eckardt L, Lewalter T, Vranckx P, Valgimigli M. Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials. Eur Heart J 2020; 40:3757-3767. [PMID: 31651946 DOI: 10.1093/eurheartj/ehz732] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/04/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS To investigate the safety and efficacy of double vs. triple antithrombotic therapy (DAT vs. TAT) in patients with atrial fibrillation (AF) and acute coronary syndrome or who underwent percutaneous coronary intervention (PCI). METHODS AND RESULTS A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials comparing DAT vs. TAT in AF patients undergoing PCI. Four trials encompassing 10 234 patients (DAT = 5496 vs. TAT = 4738) were included. The primary safety endpoint (ISTH major or clinically relevant non-major bleeding) was significantly lower with DAT compared with TAT [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.56-0.78; P < 0.0001; I2 = 69%], which was consistent across all available bleeding definitions. This benefit was counterbalanced by a significant increase of stent thrombosis (RR 1.59, 95% CI 1.01-2.50; P = 0.04; I2 = 0%) and a trend towards higher risk of myocardial infarction with DAT. There were no significant differences in all-cause and cardiovascular death, stroke and major adverse cardiovascular events. The comparison of NOAC-based DAT vs. vitamin K antagonist (VKA)-TAT yielded consistent results and a significant reduction of intracranial haemorrhage (RR 0.33, 95% CI 0.17-0.65; P = 0.001; I2 = 0%). CONCLUSION Double antithrombotic therapy, particularly if consisting of a NOAC instead of VKA and a P2Y12 inhibitor, is associated with a reduction of bleeding, including major and intracranial haemorrhages. This benefit is however counterbalanced by a higher risk of cardiac-mainly stent-related-but not cerebrovascular ischaemic occurrences.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, Bern, Switzerland.,Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, Naples, Italy
| | - Andreas Goette
- St. Vincenz-Hospital, Am Busdorf 2, Paderborn, Germany.,Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Leipziger Str. 44, Magdeburg, Germany.,Atrial Fibrillation Network (AFNET), Mendel Str.11, Münster, Germany
| | - Jan Tijssen
- Department of Cardiology, Amsterdam UMC - University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands.,Cardialysis B.V., Westblaak 98, KM Rotterdam, The Netherlands
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Mendel Str.11, Münster, Germany.,Department of Cardiology II -Electrophysiology; University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, D-48149 Münster, Germany
| | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Mendel Str.11, Münster, Germany.,Department of Cardiology and Intensive Care, Peter Osypka Heart Center Munich, Hospital Munich-South, Am Isarkanal 36, Munich/Germany
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Stadsomvaart 11, Hasselt, Belgium
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, Bern, Switzerland
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Florez WA, García-Ballestas E, Maeda F, Joaquim A, Pavlov O, Moscote-Salazar LR, Tsimpas A, Martinez-Perez R. Relationship between aspirin use and subarachnoid hemorrhage: A systematic Review and meta-analysis. Clin Neurol Neurosurg 2020; 200:106320. [PMID: 33268193 DOI: 10.1016/j.clineuro.2020.106320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aspirin has been associated with a decreasing risk of subarachnoid hemorrhage due to its anti-inflammatory mechanism of action and potential protective properties against aneurysm growth. OBJECTIVE To determine the association between aneurysmal subarachnoid hemorrhage and aspirin use. METHODS A systematic review of the literature and a meta-analysis were performed across the PubMed database. The following keywords were used: "aspirin, acetylsalicylic acid, 2-acetyloxy-benzoic acid, ruptured intracranial aneurysm, aneurysmal subarachnoid hemorrhage, spontaneous subarachnoid hemorrhage, intracerebral hemorrhage, spontaneous aneurysmal hemorrhage, spontaneous intracerebral bleeding". Studies that were performed with animals or analyzed patients with traumatic brain injury were excluded. A total of five studies were included in our meta-analysis, with a total of 19,222 patients evaluated. Statistical analysis was performed to determine the association between the use of aspirin and the risk of subarachnoid hemorrhage. RESULTS Aspirin use reduce the risk of subarachnoid hemorrhage (odds ratio [OR] 0.51, 95 % confidence interval [CI] 0.34-0.76). CONCLUSION Although some previous studies suggested that aspirin may potentially reduce the risk of subarachnoid hemorrhage, our meta-analysis found an association between the reduction of risk of aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- William A Florez
- Latinoamerican Council of Neurocritical Care, Cartagena, Colombia; Faculty of Health, Programa Medicina, Universidad Surcolombiana, Neiva, Huila, Colombia.
| | - Ezequiel García-Ballestas
- Latinoamerican Council of Neurocritical Care, Cartagena, Colombia; Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Fernando Maeda
- Department of Neurosurgery, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Andrei Joaquim
- Department of Neurosurgery, University of Campinas (UNICAMP), Sao Paulo, Brazil
| | - Orlin Pavlov
- Departament of Neurosurgery, Klinikum Fulda gAG, Fulda, Germany
| | - Luis Rafael Moscote-Salazar
- Latinoamerican Council of Neurocritical Care, Cartagena, Colombia; Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Asterios Tsimpas
- Section of Neurosurgery, Department of Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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Jacobsen AP, Raber I, McCarthy CP, Blumenthal RS, Bhatt DL, Cusack RW, Serruys PWJC, Wijns W, McEvoy JW. Lifelong Aspirin for All in the Secondary Prevention of Chronic Coronary Syndrome: Still Sacrosanct or Is Reappraisal Warranted? Circulation 2020; 142:1579-1590. [PMID: 32886529 DOI: 10.1161/circulationaha.120.045695] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Four decades have passed since the first trial suggesting the efficacy of aspirin in the secondary prevention of myocardial infarction. Further trials, collectively summarized by the Antithrombotic Trialists' Collaboration, solidified the historical role of aspirin in secondary prevention. Although the benefit of aspirin in the immediate phase after a myocardial infarction remains incontrovertible, a number of emerging lines of evidence, discussed in this narrative review, raise some uncertainty as to the primacy of aspirin for the lifelong management of all patients with chronic coronary syndrome (CCS). For example, data challenging the previously unquestioned role of aspirin in CCS have come from recent trials where aspirin was discontinued in specific clinical scenarios, including early discontinuation of the aspirin component of dual antiplatelet therapy after percutaneous coronary intervention and the withholding of aspirin among patients with both CCS and atrial fibrillation who require anticoagulation. Recent primary prevention trials have also failed to consistently demonstrate net benefit for aspirin in patients treated to optimal contemporary cardiovascular risk factor targets, indicating that the efficacy of aspirin for secondary prevention of CCS may similarly have changed with the addition of more modern secondary prevention therapies. The totality of recent evidence supports further study of the universal need for lifelong aspirin in secondary prevention for all adults with CCS, particularly in stable older patients who are at highest risk for aspirin-induced bleeding.
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Affiliation(s)
- Alan P Jacobsen
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD(A.P.J., R.S.B., J.W.M.)
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (I.R.)
| | - Cian P McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston(C.P.M.)
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD(A.P.J., R.S.B., J.W.M.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA(D.L.B.)
| | - Ronan W Cusack
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
| | - Patrick W J C Serruys
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
| | - William Wijns
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
| | - John W McEvoy
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
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Affiliation(s)
- Celina M Yong
- Stanford University School of Medicine and Cardiovascular Institute, Stanford, California
- Palo Alto VA Healthcare System, Palo Alto, California
| | - John A Bittl
- Interventional Cardiology Group, AdventHealth Ocala, Ocala, Florida
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Drakopoulou M, Soulaidopoulos S, Oikonomou G, Stathogiannis K, Latsios G, Synetos A, Tousoulis D, Toutouzas K. Novel Perspective for Antithrombotic Therapy in TAVI. Curr Pharm Des 2020; 26:2789-2803. [DOI: 10.2174/1381612826666200413083746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/29/2022]
Abstract
:
While surgical aortic valve replacement (SAVR) was for years the only available treatment for symptomatic
aortic stenosis, the introduction of transcatheter aortic valve implantation (TAVI) in 2002 and the improvement
of its technical aspects in the following years, has holistically changed the synchronous therapeutic
approach of aortic valve stenosis. Recent evidence has expanded the indication of TAVI from high to lower surgical
risk populations with symptomatic aortic stenosis. The administration of antithrombotic therapy periprocedurally
and its maintenance after a successful TAVI is crucial for the prevention of complications and affects
postprocedural survival. Randomized controlled trials investigating the appropriate combination and the
duration of antithrombotic treatment after TAVI are for the moment scarce. This review article sheds light on the
underlying pathogenetic mechanisms contributing in periprocedural TAVI thrombotic complications and discuss
the efficacy of current antithrombotic policies as evaluated in randomized trials.
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Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - George Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - George Latsios
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Andreas Synetos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
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Crescente M, Armstrong PC, Kirkby NS, Edin ML, Chan MV, Lih FB, Jiao J, Maffucci T, Allan HE, Mein CA, Gaston-Massuet C, Cottrell GS, Mitchell JA, Zeldin DC, Herschman HR, Warner TD. Profiling the eicosanoid networks that underlie the anti- and pro-thrombotic effects of aspirin. FASEB J 2020; 34:10027-10040. [PMID: 32592197 PMCID: PMC9359103 DOI: 10.1096/fj.202000312r] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/25/2022]
Abstract
Aspirin prevents thrombosis by inhibiting platelet cyclooxygenase (COX)-1 activity and the production of thromboxane (Tx)A2, a pro-thrombotic eicosanoid. However, the non-platelet actions of aspirin limit its antithrombotic effects. Here, we used platelet-COX-1-ko mice to define the platelet and non-platelet eicosanoids affected by aspirin. Mass-spectrometry analysis demonstrated blood from platelet-COX-1-ko and global-COX-1-ko mice produced similar eicosanoid profiles in vitro: for example, formation of TxA2, prostaglandin (PG) F2α, 11-hydroxyeicosatraenoic acid (HETE), and 15-HETE was absent in both platelet- and global-COX-1-ko mice. Conversely, in vivo, platelet-COX-1-ko mice had a distinctly different profile from global-COX-1-ko or aspirin-treated control mice, notably significantly higher levels of PGI2 metabolite. Ingenuity Pathway Analysis (IPA) predicted that platelet-COX-1-ko mice would be protected from thrombosis, forming less pro-thrombotic TxA2 and PGE2. Conversely, aspirin or lack of systemic COX-1 activity decreased the synthesis of anti-aggregatory PGI2 and PGD2 at non-platelet sites leading to predicted thrombosis increase. In vitro and in vivo thrombosis studies proved these predictions. Overall, we have established the eicosanoid profiles linked to inhibition of COX-1 in platelets and in the remainder of the cardiovascular system and linked them to anti- and pro-thrombotic effects of aspirin. These results explain why increasing aspirin dosage or aspirin addition to other drugs may lessen antithrombotic protection.
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Affiliation(s)
- Marilena Crescente
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Paul C Armstrong
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nicholas S Kirkby
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Matthew L Edin
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Melissa V Chan
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Fred B Lih
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Jing Jiao
- Department of Medical and Molecular Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tania Maffucci
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Harriet E Allan
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Charles A Mein
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carles Gaston-Massuet
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Graeme S Cottrell
- Reading School of Pharmacy and ICMR, University of Reading, Reading, UK
| | - Jane A Mitchell
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Darryl C Zeldin
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
| | - Harvey R Herschman
- Department of Medical and Molecular Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Timothy D Warner
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Abstract
The role of acetylsalicylic acid (ASA) in cardiovascular prevention is essentially consequence of its ability to inhibit platelet aggregation, thus reducing the impact of atherosclerotic disease. The preventive power of this drug is clear when used in patients with previous cardiovascular event (myocardial infarction, stroke, etc.), but the data are less dependable when considering patients who did not experienced a cardiovascular event or in the diabetic population, in whom recent studies reported neutral results in term of efficacy, in face of an increase in the risk of bleeding. Furthermore, the interpretation of the efficacy results of ASA should be reconsidered in light of the increasing clinical complexity, not addressed in the clinical studies on which current evidences are based. Accordingly the rationale for ASA use in cardiovascular prevention is ever more of current interest, and requires a particular attention, considering the crucial role of antithrombotic therapy in the foreseeable future. What could be learned on the use of ASA in cardiovascular prevention after a century since its chemical synthesis? In secondary prevention, supporting evidences have now a couple of decades of history, and the use of the drug appears to be firmly established: in this setting, the benefits clearly surpass the risks. On the other hand, in primary prevention, where age and diabetes are among the main risk factors, the risk/benefit ratio for prophylactic therapy with ASA does not support its widespread use. Deciding when this treatment should be implemented should require a case-by-case evaluation, considering, first, the correction of each risk factor, whose control has led to a reduction of global cardiovascular mortality. The other fundamental aspect is the compliance to the treatment, particularly in patients subjected to multiple drugs regimens, in whom the physician should take into account the specific needs of the patient, as not to provide a mere prescription service.
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Affiliation(s)
- Claudio Borghi
- Cattedra di Medicina Interna, Università degli Studi di Bologna, Bologna, Italy
| | - Fulvio Ventura
- Cattedra di Medicina Interna, Università degli Studi di Bologna, Bologna, Italy
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40
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Chiarito M, Sanz-Sánchez J, Cannata F, Cao D, Sturla M, Panico C, Godino C, Regazzoli D, Reimers B, De Caterina R, Condorelli G, Ferrante G, Stefanini GG. Monotherapy with a P2Y 12 inhibitor or aspirin for secondary prevention in patients with established atherosclerosis: a systematic review and meta-analysis. Lancet 2020; 395:1487-1495. [PMID: 32386592 DOI: 10.1016/s0140-6736(20)30315-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Antiplatelet therapy is recommended among patients with established atherosclerosis. We compared monotherapy with a P2Y12 inhibitor versus aspirin for secondary prevention. METHODS In this systematic review and meta-analysis, all randomised trials comparing P2Y12 inhibitor with aspirin monotherapy for secondary prevention in patients with cerebrovascular, coronary, or peripheral artery disease were evaluated for inclusion. On Dec 18, 2019, we searched PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials. Additionally, we reviewed references from identified articles and searched abstracts from 2017 to 2019 presented at relevant scientific meetings. Data about year of publication, inclusion and exclusion criteria, sample size, baseline patients' features including the baseline condition determining study inclusion (ie, cerebrovascular, coronary, or peripheral artery disease), P2Y12 inhibitor type and dosage, aspirin dosage, endpoint definitions, effect estimates, follow-up duration, and percentage of patients lost to follow-up were collected. Odds ratios (ORs) and 95% CIs were used as metric of choice for treatment effects with random-effects models. Co-primary endpoints were myocardial infarction and stroke. Key secondary endpoints were all-cause death and vascular death. Heterogeneity was assessed with the I2 index. This study is registered with PROSPERO (CRD42018115037). FINDINGS A total of nine randomised trials were identified and included in this study, and 42 108 patients randomly allocated to a P2Y12 inhibitor (n=21 043) or aspirin (n=21 065) were included in our analyses. Patients who received a P2Y12 inhibitor had a borderline reduction for the risk of myocardial infarction compared with those who received aspirin (OR 0·81 [95% CI 0·66-0·99]; I2=10·9%). Risks of stroke (OR 0·93 [0·82-1·06]; I2=34·5%), all-cause death (OR 0·98 [0·89-1·08]; I2=0%), and vascular death (OR 0·97 [0·86-1·09]; I2=0%) did not differ between patients who received a P2Y12 inhibitor and those who received aspirin. Similarly, the risk of major bleeding (OR 0·90 [0·74-1·10]; I2=3·9%) did not differ between patients who received a P2Y12 inhibitor and those who received aspirin. The number needed to treat to prevent one myocardial infarction with P2Y12 inhibitor monotherapy was 244 patients. Findings were consistent regardless of the type of P2Y12 inhibitor used. INTERPRETATION Compared with aspirin monotherapy, P2Y12 inhibitor monotherapy is associated with a risk reduction for myocardial infarction and a comparable risk of stroke in the setting of secondary prevention. The benefit of P2Y12 inhibitor monotherapy is of debatable clinical relevance, in view of the high number needed to treat to prevent a myocardial infarction and the absence of any effect on all-cause and vascular mortality. FUNDING Italian Ministry of Education.
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Affiliation(s)
- Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Jorge Sanz-Sánchez
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Davide Cao
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Matteo Sturla
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cristina Panico
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Damiano Regazzoli
- Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Raffaele De Caterina
- University of Pisa, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giuseppe Ferrante
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Rozzano, Milan, Italy.
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Abstract
The antiplatelet landscape for the secondary prevention of ischemic stroke has changed significantly over the past decade. Poststroke dual antiplatelet regimens are becoming increasingly routine as supported by recent literature and guideline recommendations. Dual antiplatelet therapy after stroke generally consists of aspirin and clopidogrel and is considered in the short term after stroke in select populations including those with mild stroke or transient ischemic attack and in patients with severe intracranial atherosclerosis. When initiating dual antiplatelet therapy, factors that may increase a patient's risk of bleeding must be weighed against the patient's risk of future ischemic events. This review focuses on antiplatelet medications available in the United States with the aim to provide a summary of the available literature on poststroke dual antiplatelet therapy, pharmacological nuances of the agents, and reversal of antiplatelets in the setting of intracerebral hemorrhage.
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42
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Franzone A, McFadden E, Leonardi S, Piccolo R, Vranckx P, Serruys PW, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, Diletti R, Dominici M, Huber K, Slagboom T, Buszman P, Bolognese L, Tumscitz C, Bryniarski K, Aminian A, Vrolix M, Petrov I, Garg S, Naber C, Prokopczuk J, Hamm C, Steg PG, Heg D, Jüni P, Windecker S, Valgimigli M. Ticagrelor Alone Versus Dual Antiplatelet Therapy From 1 Month After Drug-Eluting Coronary Stenting. J Am Coll Cardiol 2019; 74:2223-2234. [DOI: 10.1016/j.jacc.2019.08.1038] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 08/08/2019] [Accepted: 08/10/2019] [Indexed: 11/17/2022]
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43
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Väyrynen JP, Väyrynen SA, Sirniö P, Minkkinen I, Klintrup K, Karhu T, Mäkelä J, Herzig KH, Karttunen TJ, Tuomisto A, Mäkinen MJ. Platelet count, aspirin use, and characteristics of host inflammatory responses in colorectal cancer. J Transl Med 2019; 17:199. [PMID: 31196200 PMCID: PMC6567577 DOI: 10.1186/s12967-019-1950-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/05/2019] [Indexed: 02/08/2023] Open
Abstract
Background Platelets not only contribute to hemostasis but also to the regulation of inflammatory reactions and cancer pathogenesis. We hypothesized that blood platelet count would be associated with systemic inflammation, the densities of tumor infiltrating immune cells, and survival in colorectal cancer (CRC), and these relationships could be altered by aspirin use. Methods We measured blood platelet count in a cohort of 356 CRC patients and analyzed its relationships with tumor and patient characteristics including aspirin use, markers of systemic inflammation (modified Glasgow Prognostic Score, mGPS; serum levels of CRP, albumin, and 13 cytokines), blood hemoglobin levels, five types of tumor infiltrating immune cells (CD3, CD8, FoxP3, Neutrophil elastase, mast cell tryptase), and survival. Results Platelet count inversely correlated with blood hemoglobin levels (p < 0.001) and positively correlated with serum levels of CRP and multiple cytokines including IL-1RA, IL-4, IL-6, IL-7, IL-8, IL-12, IFNγ, and PDGF-BB (p < 0.001 for all), while aspirin use was not associated with the levels of systemic inflammatory markers. High platelet count was also associated with high mGPS (p < 0.001) but did not show statistically significant multivariable adjusted associations with the densities of tumor infiltrating immune cells. Higher platelet counts were observed in higher tumor stage (p < 0.001), but platelet count or aspirin use were not associated with patient survival. Conclusions High platelet count is associated with systemic inflammation in CRC. This study could not demonstrate statistically significant associations between platelet count, aspirin use, and the densities of tumor infiltrating immune cells. Electronic supplementary material The online version of this article (10.1186/s12967-019-1950-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juha P Väyrynen
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland. .,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland. .,Department of Oncologic Pathology, Dana-Farber Cancer Institute and Harvard Medical School, 450 Brookline Ave, Boston, MA, 02215, USA.
| | - Sara A Väyrynen
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland.,Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Päivi Sirniö
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Ilkka Minkkinen
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Kai Klintrup
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Surgery, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Toni Karhu
- Research Unit of Biomedicine and Biocenter of Oulu, University of Oulu, POB 5000, 90014, Oulu, Finland.,Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Jyrki Mäkelä
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Surgery, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Karl-Heinz Herzig
- Research Unit of Biomedicine and Biocenter of Oulu, University of Oulu, POB 5000, 90014, Oulu, Finland.,Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland.,Department of Gastroenterology and Metabolism, Poznan University of Medical Sciences, ul. Szpitalna 27/33, 60-572, Poznan, Poland
| | - Tuomo J Karttunen
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Anne Tuomisto
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
| | - Markus J Mäkinen
- Cancer and Translational Medicine Research Unit, University of Oulu, POB 5000, 90014, Oulu, Finland.,Department of Pathology, Oulu University Hospital and Medical Research Center Oulu, POB 21, 90029, Oulu, Finland
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Shimizu A, Sonoda S, Muraoka Y, Setoyama K, Inoue K, Miura T, Anai R, Sanuki Y, Miyamoto T, Oginosawa Y, Tsuda Y, Araki M, Otsuji Y. Bleeding and ischemic events during dual antiplatelet therapy after second-generation drug-eluting stent implantation in hemodialysis patients. J Cardiol 2019; 73:470-478. [DOI: 10.1016/j.jjcc.2018.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
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45
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Leonardi S, Franzone A, Piccolo R, McFadden E, Vranckx P, Serruys P, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, van Geuns RJ, Dominici M, Huber K, Slagboom T, Buszman P, Bolognese L, Tumscitz C, Bryniarski K, Aminian A, Vrolix M, Petrov I, Garg S, Naber C, Prokopczuk J, Hamm C, Steg G, Heg D, Juni P, Windecker S, Valgimigli M. Rationale and design of a prospective substudy of clinical endpoint adjudication processes within an investigator-reported randomised controlled trial in patients with coronary artery disease: the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY). BMJ Open 2019; 9:e026053. [PMID: 30852547 PMCID: PMC6429932 DOI: 10.1136/bmjopen-2018-026053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The GLOBAL LEADERS is an open-label, pragmatic and superiority randomised controlled trial designed to challenge the current treatment paradigm of dual antiplatelet therapy (DAPT) for 12 months followed by aspirin monotherapy among patients undergoing percutaneous coronary intervention. By design, all study endpoints are investigator reported (IR) and not subject to formal adjudication by an independent Clinical Event Committee (CEC), which may introduce detection, reporting or ascertainment bias. METHODS AND ANALYSIS We designed the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY) to prospectively implement, in a large sample of patients enrolled within the GLOBAL LEADERS trial (7585 of 15 991, 47.5%), an independent adjudication process of reported and unreported potential endpoints, using standardised CEC procedures, in order to assess whether 23-month ticagrelor monotherapy (90 mg twice daily) after 1-month DAPT is non-inferior to a standard regimen of DAPT for 12 months followed by aspirin monotherapy for the primary efficacy endpoint of death, non-fatal myocardial infarction, non-fatal stroke or urgent target vessel revascularisation and superior for the primary safety endpoint of type 3 or 5 bleeding according to the Bleeding Academic Research Consortium criteria.This study will comprehensively assess the comparative safety and efficacy of the two tested antithrombotic strategies on CEC-adjudicated ischaemic and bleeding endpoints and will provide insights into the role of a standardised CEC adjudication process on the interpretation of study findings by quantifying the level of concordance between IR-reported and CEC-adjudicated events. ETHICS AND DISSEMINATION GLASSY has been approved by local ethics committee of all study sites and/or by the central ethics committee for the country depending on country-specific regulations. In all cases, they deemed that it was not necessary to obtain further informed consent from individual subjects. TRIAL REGISTRATION NUMBER NCT01813435.
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Affiliation(s)
- Sergio Leonardi
- University of Pavia, Department of Molecular Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Eugene McFadden
- Department of Cardiology, Cork University Hospital Group, Cork, Ireland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Patrick Serruys
- Department of Cardiology, Imperial College of London, London, UK
| | - Edouard Benit
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Luc Janssens
- Department of Cardiology, Imelda Hospital, Bonheiden, Belgium
| | - Maurizio Ferrario
- Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Aleksander Zurakowski
- Center of Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | | | - Marcello Dominici
- Department of Cardiology, S. Maria University-Hospital, Terni, Italy
| | - Kurt Huber
- 3rd Med Department, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Austria
| | - Ton Slagboom
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | - Paweł Buszman
- Center for Cardiovascular Research and Development, American Heart of Poland, Poland, Poland
| | | | - Carlo Tumscitz
- Department of Cardiology, Azienda Ospedaliero Universitaria di Ferrara Arcispedale Sant’Anna, Cona, Italy
| | - Krzysztof Bryniarski
- Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Mathias Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ivo Petrov
- Department of Cardiology, Adzhibadem Siti Klinik Surdechno-sudovi Center, Sofia, Bulgaria
| | - Scot Garg
- Department of Cardiology, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Christoph Naber
- Department of Cardiology and Angiology, Contilia Heart and Vascular Centre, Essen, Germany
| | | | | | - Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Dik Heg
- CTU, Institute of Social and Preventive Medicine and Clinical Trials Unit, Bern, Switzerland
| | - Peter Juni
- Department of Medicine, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Canada
| | - Stephan Windecker
- Department of Cardiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital Universitatsspital Bern, Bern, Switzerland
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Ranasinghe MP, Peter K, McFadyen JD. Thromboembolic and Bleeding Complications in Transcatheter Aortic Valve Implantation: Insights on Mechanisms, Prophylaxis and Therapy. J Clin Med 2019; 8:jcm8020280. [PMID: 30823621 PMCID: PMC6406714 DOI: 10.3390/jcm8020280] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/09/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an important alternative to surgical aortic valve repair (SAVR) for patients with severe aortic stenosis. This rapidly advancing field has produced new-generation devices being delivered with small delivery sheaths, embolic protection devices and improved retrieval features. Despite efforts to reduce the rate of thrombotic complications associated with TAVI, valve thrombosis and cerebral ischaemic events post-TAVI continue to be a significant issue. However, the antithrombotic treatments utilised to prevent these dreaded complications are based on weak evidence and are associated with high rates of bleeding, which in itself is associated with adverse clinical outcomes. Recently, experimental data has shed light on the unique mechanisms, particularly the complex haemodynamic changes at sites of TAVI, that underpin the development of post-TAVI thrombosis. These new insights regarding the drivers of TAVI-associated thrombosis, coupled with the ongoing development of novel antithrombotics which do not cause bleeding, hold the potential to deliver newer, safer therapeutic paradigms to prevent post-TAVI thrombotic and bleeding complications. This review highlights the major challenge of post-TAVI thrombosis and bleeding, and the significant issues surrounding current antithrombotic approaches. Moreover, a detailed discussion regarding the mechanisms of post-TAVI thrombosis is provided, in addition to an appraisal of current antithrombotic guidelines, past and ongoing clinical trials, and how novel therapeutics offer the hope of optimizing antithrombotic strategies and ultimately improving patient outcomes.
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Affiliation(s)
- Mark P Ranasinghe
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
- Heart Centre, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
| | - James D McFadyen
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
- Department of Clinical Haematology, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
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Sychev DA, Shprakh VV, Kitaeva EY, Mirzaev KB, Mickhalevich IM. Genetic and non-genetic factors of laboratory resistance to clopidogrel in patients with ischemic stroke. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:45-52. [DOI: 10.17116/jnevro201911903245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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48
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ACC/AHA Versus ESC Guidelines on Dual Antiplatelet Therapy. J Am Coll Cardiol 2018; 72:2915-2931. [DOI: 10.1016/j.jacc.2018.09.057] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/05/2018] [Accepted: 09/08/2018] [Indexed: 01/25/2023]
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49
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Bittl JA. Using Ticagrelor to Prevent Recurrent Type 1 and Type 2 Myocardial Infarctions: Boon or Bane? J Am Heart Assoc 2018; 7:e010996. [PMID: 30571508 PMCID: PMC6404457 DOI: 10.1161/jaha.118.010996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 11/27/2022]
Abstract
See Editorial by Bonaca et al.
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Affiliation(s)
- John A. Bittl
- Interventional Cardiology GroupFlorida Hospital OcalaOcalaFL
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50
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Costa F, Windecker S, Valgimigli M. Dual Antiplatelet Therapy Duration: Reconciling the Inconsistencies. Drugs 2018; 77:1733-1754. [PMID: 28853033 DOI: 10.1007/s40265-017-0806-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Dual antiplatelet therapy (DAPT) prevents recurrent ischemic events after an acute coronary syndrome (ACS) as well as stent thrombosis (ST) in patients with prior stent implantation. Nevertheless, these benefits are counterbalanced by a significant bleeding hazard, which is directly related to the treatment duration. Although DAPT has been extensively studied in numerous clinical trials, optimal treatment duration is still debated, mostly because of apparent inconsistencies among studies. Shortened treatment duration of 6 or 3 months was shown to mitigate bleeding risk compared with consensus-grounded 12-month standard duration, without any apparent excess of ischemic events. However, recent trials showed that a >12-month course of treatment reduces ischemic events but increases bleeding compared with 12 months. The inconsistent benefit of a longer DAPT course compared with shorter treatment durations is puzzling, and requires a careful appraisal of between-studies differences. We sought to summarize the existing evidence aiming at reconciling apparent inconsistencies among these studies, as well as thoroughly discuss the possible increased risk of fatal events associated with long-term DAPT. Benefits and risks of prolonging or shortening DAPT duration will be discussed, with a focus on treatment individualization. Finally, we will provide an outlook for possible future directions in the field.
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Affiliation(s)
- Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic "G. Martino", University of Messina, Messina, Italy
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stephan Windecker
- Swiss Cardiovascular Center Bern, Bern University Hospital, 3010, Bern, Switzerland
| | - Marco Valgimigli
- Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands.
- Swiss Cardiovascular Center Bern, Bern University Hospital, 3010, Bern, Switzerland.
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