1
|
Ortega-Paz L, Franchi F, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Mahowald MK, Langaee T, Jakubowski JA, Cavallari LH, Angiolillo DJ. Clopidogrel-Mediated P2Y 12 Inhibition According to Renal Function in Patients With Diabetes Mellitus and CAD. JACC Basic Transl Sci 2024; 9:865-876. [PMID: 39170956 PMCID: PMC11334417 DOI: 10.1016/j.jacbts.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/12/2024] [Accepted: 03/12/2024] [Indexed: 08/23/2024]
Abstract
This prospective ex vivo and in vitro pharmacodynamic (PD)/pharmacokinetic investigation was conducted in patients with diabetes mellitus with (n = 31) and without chronic kidney disease (n = 30). PD assessments included platelet reactivity index, maximum platelet aggregation, and P2Y12 reaction units. Ex vivo pharmacokinetic assessments included plasma levels of clopidogrel and its active metabolite. In vitro PD assessments were conducted on baseline samples incubated with escalating concentrations of clopidogrel and its active metabolite. Among patients with diabetes mellitus treated with clopidogrel, impaired renal function was associated with increased maximum platelet aggregation. This finding could be attributed partially to upregulation of the P2Y12 activity without differences in drug absorption or metabolism. (Impact of Chronic Kidney Disease on Clopidogrel Effects in Diabetes Mellitus; NCT03774394).
Collapse
Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Andres M. Pineda
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Martin M. Zenni
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Madeline K. Mahowald
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy University of Florida, Gainesville, Florida, USA
| | | | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy University of Florida, Gainesville, Florida, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| |
Collapse
|
2
|
Case BC, Torguson R, Abramowitz J, Shea C, Zhang C, Sutton JA, Deksissa T, Satler LF, Ben-Dor I, Bernardo NL, Hashim H, Rogers T, Waksman R. Impact of Close Surveillance on Dual-Antiplatelet Therapy Compliance in Myocardial Infarction Patients Post-Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 48:7-14. [PMID: 36347732 DOI: 10.1016/j.carrev.2022.10.007] [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: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay regimen for acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI). We aimed to investigate DAPT compliance and switching patterns in ACS patients prescribed ticagrelor and aspirin. Secondly, we evaluated the impact of a pilot strategy of close surveillance telephone calls. METHODS The study enrolled 150 consecutive ACS patients who underwent PCI and were prescribed DAPT (aspirin and ticagrelor). This cohort, the "close surveillance arm," then received telephone calls from a healthcare professional to inquire about DAPT for up to one year. These findings, and clinical outcomes, were then compared to a "historical arm" of ACS patients (n = 505) who received PCI and were prescribed DAPT before initiation of the program. Finally, healthcare providers were surveyed about their experience with prescribing DAPT. RESULTS The rate of ticagrelor cessation trended lower in the close surveillance arm (22.00 % versus 31.70 %, p = 0.0783). The most common reasons for ticagrelor cessation were adverse medication reaction (dyspnea), bleeding, and financial burden. Nevertheless, the adverse events were few and similar between the two groups during follow-up. Over 96 % of healthcare providers surveyed stated that they worry about their patients' DAPT compliance post-PCI. CONCLUSION Noncompliance and switching medications are still common for patients who undergo PCI for ACS. A close surveillance program identified patients at risk for medication cessation or switching and could potentially mitigate this phenomenon and improve quality of care.
Collapse
Affiliation(s)
- Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Rebecca Torguson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Jonathan Abramowitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Corey Shea
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Joseph A Sutton
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Teshome Deksissa
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hayder Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
| |
Collapse
|
3
|
Franchi F, Ortega-Paz L, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Reiter B, Jilma B, Angiolillo DJ. Cangrelor in Patients With Coronary Artery Disease Pretreated With Ticagrelor: The Switching Antiplatelet (SWAP)-5 Study. JACC Cardiovasc Interv 2023; 16:36-46. [PMID: 36317958 DOI: 10.1016/j.jcin.2022.10.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are no studies specifically designed to rule out a drug-drug interaction (DDI) when cangrelor is used among patients who have been pretreated with ticagrelor. OBJECTIVES This study sought to rule out a DDI among cangrelor-treated patients who have been pretreated with ticagrelor. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover, pharmacokinetic (PK) and pharmacodynamic (PD) study, patients with coronary artery disease (N = 20) were pretreated with a 180-mg ticagrelor loading dose and after 1 hour randomized to placebo or cangrelor (bolus and infusion for 2 hours). Patients crossed over after 1 to 4 weeks of washout. PK analysis included ticagrelor plasma levels and its active metabolite. PD assessments included VerifyNow P2Y12 reaction units (PRU), light transmittance aggregometry, vasodilator-stimulated phosphoprotein, and Total Thrombus-Formation Analysis System. PK/PD assessments were performed at 7 time points. RESULTS Compared with placebo, adding cangrelor to patients pretreated with ticagrelor resulted in a significant reduction in PRU at 30 minutes and 1 hour after starting infusion. At 2 hours after stopping cangrelor/placebo infusion, PRU were low and similar in both groups (16.9 vs 12.6; mean difference: 4.3; 95% CI: -28.6 to 37.3), meeting the noninferiority primary endpoint (predefined noninferiority margin 45 PRU). Consistent findings were shown with all PD assays. PK tracked PD findings with no differences between groups in plasma levels of ticagrelor and its metabolite. CONCLUSIONS Compared with placebo, the use of cangrelor in patients pretreated with ticagrelor results in enhanced platelet inhibition with no differences in PK/PD profiles after discontinuation of drug infusion indicating the absence of a DDI. (PD and PK Profiles of Switching Between Cangrelor and Ticagrelor Following Ticagrelor Pre-treatment [SWAP-5]; NCT04634162).
Collapse
Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.
| |
Collapse
|
4
|
The developmental journey of therapies targeting purine receptors: from basic science to clinical trials. Purinergic Signal 2022; 18:435-450. [PMID: 36173587 PMCID: PMC9832190 DOI: 10.1007/s11302-022-09896-w] [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: 04/28/2022] [Accepted: 07/21/2022] [Indexed: 01/14/2023] Open
Abstract
Since the discovery of ATP as an extracellular signalling molecule in 1972, purinergic signalling, mediated by extracellular purines and pyrimidines has been identified in virtually all mammalian tissues and is implicated in regulating fundamental cellular processes. In recent years, there has been an increasing focus on the pathophysiology and potential therapeutic interventions based on purinergic signalling. A vast range of compounds targeting purine receptors are in clinical development, and many more are in preclinical studies, which highlights the fast growth in this research field. As a tribute to Professor Geoffrey Burnstock's legacy in purinergic signalling, we present here a brief review of compounds targeting purine receptors that are in different stages of clinical trials. The review highlights the 50-year journey from basic research on purinergic receptors to clinical applications of therapies targeting purine receptors.
Collapse
|
5
|
Mazzone PM, Angiolillo DJ, Capodanno D. Approaches to de-escalation of antiplatelet treatment in stabilized post-myocardial infarction patients with high ischemic risk. Expert Rev Cardiovasc Ther 2022; 20:839-849. [DOI: 10.1080/14779072.2022.2137492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, 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
| |
Collapse
|
6
|
Galli M, Angiolillo DJ. De-escalation of antiplatelet therapy in acute coronary syndromes: Why, how and when? Front Cardiovasc Med 2022; 9:975969. [PMID: 36093167 PMCID: PMC9452742 DOI: 10.3389/fcvm.2022.975969] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 12/29/2022] Open
Abstract
The synergistic blockade of the key platelet signaling pathways of cyclooxygenase-1 blockade and P2Y12 signaling by combining aspirin plus a potent P2Y12 inhibitor (prasugrel or ticagrelor), the so called dual antiplatelet treatment (DAPT), has represented the antithrombotic regimen of choice in patients with acute coronary syndrome (ACS) for nearly a decade. Nevertheless, the use of such antiplatelet treatment regimen, while reduced the risk of thrombotic complications, it is inevitably associated with increased bleeding and this risk may outweigh the benefit of a reduction of ischemic events in specific subgroup of patients. In light of the adverse prognostic implications of a bleeding complication, there has been a great interest in the development of antiplatelet regimens aimed at reducing bleeding without any trade-off in ischemic events. The fact that the ischemic risk is highest in the early phase after an ACS while the risk of bleeding remains relatively stable over time has represented the rationale for the implementation of a more intense antithrombotic regimen early after an ACS, followed by a less intense antithrombotic regimen thereafter. This practice, known as a "de-escalation" strategy, represents one of the more promising approaches for personalization of antithrombotic therapy in ACS. In this review we discuss the rationale, appraise the evidence and provide practical recommendations on the use of a de-escalation strategy of antiplatelet therapy in patients with an ACS.
Collapse
Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| |
Collapse
|
7
|
Galli M, Ortega-Paz L, Franchi F, Rollini F, Angiolillo DJ. Precision medicine in interventional cardiology: implications for antiplatelet therapy in patients undergoing percutaneous coronary intervention. Pharmacogenomics 2022; 23:723-737. [PMID: 35938534 DOI: 10.2217/pgs-2022-0057] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Precision medicine is a medical model that proposes the customization of medical treatments to the individual patient, as opposed to a one-drug-fits-all model. Such a "personalized medicine" approach has been widely adopted in several medical fields, such as cancer medicine, but the implementation of precision medicine in cardiovascular medicine has not been similarly straightforward. Because pharmacogenomics plays an important role in the safety and efficacy of cardiovascular drug therapy, there has been a great interest in the use of tools aiming at personalizing antiplatelet therapy. Moreover, antiplatelet therapy is essential for the treatment of cardiovascular patients to reduce the risk of thrombotic complications, particularly those undergoing percutaneous coronary intervention, but it is inevitably associated with increased bleeding risk. In this review, the authors discuss the rationale, summarize the evidence and discuss the current and future directions for the personalization of antiplatelet treatment regimens in patients undergoing percutaneous coronary intervention.
Collapse
Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| |
Collapse
|
8
|
De-escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: An Updated Meta-analysis and Trial Sequential Analysis of 21 Studies and 38,741 Patients. J Cardiovasc Pharmacol 2022; 79:873-886. [PMID: 35500147 DOI: 10.1097/fjc.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/12/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Dual antiplatelet therapy (DAPT) is recommended among patients with established acute coronary syndrome. In this meta-analysis, we sought to compare the clinical outcomes between de-escalation versus unchanged DAPT based on both randomized controlled trials (RCTs) and observational studies. The primary outcomes were major adverse cardiovascular events for observational studies and net clinical events for RCTs. Four RCTs and 17 observational studies with a total of 38,741 patients were included. Net clinical events were more common with unchanged DAPT than with de-escalation in RCTs [odd ratio (OR): 1.71; 95% confidence interval (CI), 1.21-2.43; I2 = 69.4%], which was mainly due to higher risks of any bleeding (OR: 1.81; 95% CI, 1.14-2.88; I2 = 75.5%) and major bleeding (OR: 1.58; 95% CI, 1.02-2.46; I2 = 0), without significant differences in ischaemic events. However, trial sequential analysis revealed that sufficient information was obtained just for net clinical events, not for respective ischaemic or bleeding events in RCTs. In the analysis based on real-world observational studies, the risks of myocardial infarction (OR: 0.77; 95% CI, 0.61-0.98; I2 = 0) and stroke (OR: 0.42; 95% CI, 0.22-0.81; I2 = 0) were lower with the unchanged DAPT group. Therefore, de-escalation of DAPT led to a marked reduction in net clinical events compared with unchanged DAPT in RCTs, which was mainly due to reduced bleeding events. However, sufficient information for ischaemic events was not obtained. In the analysis based on real-world observational studies, myocardial infarction and stroke were more common with de-escalation, which should arise our attention.
Collapse
|
9
|
Real-World Use and Outcomes of Oral Antiplatelets Among Patients with Acute Coronary Syndrome: A Retrospective Cohort Study. Drugs Real World Outcomes 2021; 9:121-127. [PMID: 34780040 PMCID: PMC8844330 DOI: 10.1007/s40801-021-00283-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Acute coronary syndrome (ACS)-related readmission is an important hospital quality measure. Medication management therapy, especially adherence to antiplatelet agents post discharge, could play an important role in reducing readmission rates. Newer agents such as ticagrelor and prasugrel have been shown, in randomized control trials, to have superior effectiveness to cardiovascular outcomes compared to clopidogrel, but they are more expensive and have more common adverse events such as bleeding and dyspnea. OBJECTIVE We compared real-world readmission rates and adherence to antiplatelet agents among patients who initiated these agents post discharge. METHODS This was a retrospective cohortstudy of patients with an index ACS-related hospitalization between 1 July 2017 and 31 December 2018. Using integrated pharmacy and medical claims data from a large national pharmacy benefits manager for commercially insured adults aged ≥ 18 years, we compared ACS-related readmission and medication adherence (as medication possession ratio (MPR)) among the three agents. ANOVA and logistic regression, controlling for demographics such as age, gender, and Charlson Comorbidity Index, were used to estimate any association between the agents and 365-day readmission rates. RESULTS Of the 948 eligible patients, 86, 342, and 520 were initiated on prasugrel, ticagrelor, and clopidogrel (PTC), respectively. There were 4.7%, 5.3%, and 8.5% readmissions rates in the PTC cohorts, respectively, but these were not statistically significant in either the ANOVA or the logistic regression analyses. MPR was highest in the ticagrelor (88.1%) cohort, followed by the prasugrel (79.1%) and clopidogrel (76.4%) cohorts. CONCLUSION Ticagrelor cohort had the highest medication adherence. Clopidogrel cohort had the highest readmission rate but the difference with the other cohorts was statistically insignificant.
Collapse
|
10
|
Rahhal A, Aljundi A, Ibrahim Mohamed SS, Arif MA, Arabi AR. Prolonged ventricular pause associated with ticagrelor use: A case report. Clin Case Rep 2021; 9:e05017. [PMID: 34721870 PMCID: PMC8543052 DOI: 10.1002/ccr3.5017] [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: 07/02/2021] [Revised: 08/31/2021] [Accepted: 10/07/2021] [Indexed: 01/20/2023] Open
Abstract
CASE We report a case of a 76-year-old female who presented with non-ST elevation myocardial infarction and developed a 22-second ventricular pause with ticagrelor that did not recur after shifting to clopidogrel. Based on the Naranjo algorithm, the likelihood that our patient's prolonged ventricular pause was due to ticagrelor exposure was probable. CONCLUSION Ticagrelor use is associated with prolonged ventricular pauses, warranting close monitoring, particularly during the first week of therapy.
Collapse
Affiliation(s)
- Alaa Rahhal
- Pharmacy DepartmentHeart HospitalHamad Medical CorporationDohaQatar
| | - Amer Aljundi
- Pharmacy DepartmentHeart HospitalHamad Medical CorporationDohaQatar
| | | | | | | |
Collapse
|
11
|
Coronary Heart Disease (CHD) in Elderly Patients: Which Drug to Choose, Ticagrelor and Clopidogrel? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Dev Dis 2021; 8:jcdd8100123. [PMID: 34677192 PMCID: PMC8538993 DOI: 10.3390/jcdd8100123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/13/2021] [Accepted: 09/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background: A new generation P2Y12 receptor inhibitor (ticagrelor) is recommended in current therapeutic guidelines to treat patients with coronary heart disease (CHD). However, it is unknown if ticagrelor is more effective than clopidogrel in elderly patients. Therefore, a systematic review was done to assess the effectiveness and safety of ticagrelor and clopidogrel in older patients with CHD to determine the appropriate antiplatelet treatment plan. Methodology: We performed a systematic review of randomized controlled trials (RCTs) to compare the effectiveness and safety of ticagrelor vs. clopidogrel in elderly patients with CHD. We selected eligible RCTs based on specified study criteria following a systematic search of PubMed and Scopus databases from January 2007 to May 2021. Primary efficacy outcomes assessed were major adverse cardiovascular events (MACEs), myocardial infarction (MI), stent thrombosis (ST), and all-cause death. The secondary outcome assessed was major bleeding events. We used RevMan 5.3 software to conduct a random-effects meta-analysis and estimated the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs) for ticagrelor and clopidogrel. Results: Data from 6 RCTs comprising 21,827 elderly patients were extracted according to the eligibility criteria. There was no significant difference in the MACE outcome (incidence: 9.23% vs. 10.57%; RR = 0.95, 95% CI = 0.70–1.28, p = 0.72), MI (incidence: 5.40% vs. 6.23%; RR = 0.94, 95% CI= 0.69–1.27, p = 0.67), ST (incidence: 2.33% vs. 3.17%; RR = 0.61, 95% CI= 0.32–1.17, p = 0.13), and all-cause death (4.29% vs. 5.33%; RR = 0.86, 95% CI = 0.65–1.12, p = 0.25) for ticagrelor vs. clopidogrel, respectively. In addition, ticagrelor was not associated with a significant increase in the rate of major bleeding (incidence: 9.98% vs. 9.33%: RR = 1.37, 95% CI = 0.97–1.94, p = 0.07) vs. clopidogrel. Conclusions: This study did not find evidence that ticagrelor is significantly more effective or safer than clopidogrel in elderly patients with CHD.
Collapse
|
12
|
Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| |
Collapse
|
13
|
Franchi F, Rollini F, Been L, Maaliki N, Jaoude PA, Rivas A, Zhou X, Jia S, Briceno M, Lee CH, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Impact Of Chronic Kidney Disease On The Pharmacodynamic And Pharmacokinetic Effects Of Ticagrelor In Patients With Diabetes Mellitus And Coronary Artery Disease. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:452-461. [PMID: 34114623 DOI: 10.1093/ehjcvp/pvab042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/06/2021] [Indexed: 12/15/2022]
Abstract
AIMS Patients with diabetes mellitus (DM) and chronic kidney disease (CKD) are at increased risk of atherothrombotic events. Ticagrelor reduces ischaemic events compared to clopidogrel, with the greatest risk reduction in patients with both DM and CKD. How CKD status affects the pharmacodynamic (PD) and pharmacokinetic (PK) profiles of different ticagrelor maintenance dose regimens in patients with DM is unknown. METHODS AND RESULTS In this randomized, cross-over study, patients with DM on treatment with dual antiplatelet therapy (aspirin and clopidogrel) were stratified according to CKD status and randomized to ticagrelor 90 mg bid or 60 mg bid. PK/PD assessments were performed at baseline, after 7-10 days of ticagrelor (peak and trough), and after 7-10 days of alternative ticagrelor regimen (peak and trough). PK assessments included plasma concentrations of ticagrelor and its major metabolite. PD assessments included VASP-PRI, VerifyNow P2Y12, and LTA.A total of 92 patients with DM (CKD, n = 44; non-CKD, n = 48) were randomized. Levels of platelet reactivity were lower with the 90 mg compared with the 60 mg ticagrelor dose, which was statistically significant in non-CKD but not in CKD patients for most PD measures. There were no significant differences in the primary endpoint (trough levels of VASP-PRI following ticagrelor 90 mg dosing) between cohorts (31 ± 20 vs 25 ± 14; p = 0.105). VerifyNow and LTA provided similar findings. PK assessments tracked PD profiles showing increased plasma concentrations of ticagrelor and its major metabolite in CKD compared to non-CKD patients. CONCLUSION In patients with DM, although ticagrelor maintenance dose regimens (60 mg and 90 mg) yield potent P2Y12 inhibition, levels of platelet reactivity tended to be higher and subject to broader variability in non-CKD compared with CKD patients. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov Unique Identifier: NCT02539160.
Collapse
Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Latonya Been
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Naji Maaliki
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Patrick Abou Jaoude
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Andrea Rivas
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Xuan Zhou
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sida Jia
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Maryuri Briceno
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Chang Hoon Lee
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Andres M Pineda
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Siva Suryadevara
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Daniel Soffer
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Martin M Zenni
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Theodore A Bass
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | | |
Collapse
|
14
|
Switching Ticagrelor to 600 mg or 300 mg Clopidogrel Loading Bridge in Patients with Unstable Angina. J Clin Med 2021; 10:jcm10112463. [PMID: 34199404 PMCID: PMC8199609 DOI: 10.3390/jcm10112463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 01/26/2023] Open
Abstract
Ticagrelor is believed to be a more potent and faster antiplatelet agent compared with clopidogrel and may result in lower ischemic outcomes in patients with acute coronary syndrome. However, the best strategy of switching from ticagrelor to clopidogrel is unclear. Current guidelines advocate clopidogrel bridging with a 600 mg loading dose (LD). This study aimed to compare the safety and feasibility of switching protocols from ticagrelor to clopidogrel 600 mg or 300 mg LD in patients with unstable angina pectoris (USAP). One hundred and eighty patients with USAP undergoing adhoc percutaneous coronary intervention (PCI) received preprocedural ticagrelor 180 mg/daily. The decision to switch antiplatelet therapy to clopidogrel with either 300 mg LD or 600 mg LD at 12 h was left to the discretion of the treating physician. The primary outcome was a composite of an efficacy endpoint major adverse cardiac and cerebrovascular events (MACCEs) and a safety endpoint Bleeding Academic Research Consortium scale (BARC) (≥1). There were no differences in our composite clinical endpoint of MACCE between the two strategies, with one event occurring in each group. One patient in each group had myocardial infarction due to stent thrombosis, and the patient in the 300 mg switching group died due to stent thrombosis. No difference between the two arms was observed in terms of BARC bleeding criteria. This study showed that among USAP patients undergoing PCI, switching to clopidogrel with 300 mg LD showed no significant difference compared to 600 mg clopidogrel LD. Ticagrelor LD in ad hoc PCI and de-escalation to clopidogrel with 300 mg LD could translate to lower costs for patients with USAP without compromising safety and efficacy.
Collapse
|
15
|
The effect of de-escalation of P2Y12 receptor inhibitor therapy after acute myocardial infarction in patients undergoing percutaneous coronary intervention: A nationwide cohort study. PLoS One 2021; 16:e0246029. [PMID: 33493236 PMCID: PMC7833092 DOI: 10.1371/journal.pone.0246029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 01/12/2021] [Indexed: 01/31/2023] Open
Abstract
To examine the effect of de-escalation of P2Y12 inhibitor in dual antiplatelet therapy (DAPT) on major adverse cardiovascular events (MACE) and bleeding complications after acute myocardial infarction (AMI) in Taiwanese patients undergoing percutaneous coronary intervention (PCI). Patients who had received PCI during hospitalization for AMI (between 2013 and 2016) and were initially treated with aspirin and ticagrelor and without adverse events after 3 months of treatment were retrospectively evaluated. In total, 1,901 and 8,199 patients were identified as “de-escalated DAPT” (switched to aspirin and clopidogrel) and “unchanged DAPT” (continued on aspirin and ticagrelor) cohorts, respectively. With a mean follow-up of 8 months, the incidence rates (per 100 person-year) of death, AMI readmission and MACE were 2.89, 3.68, and 4.91 in the de-escalated cohort and 2.42, 3.28, and 4.72 in the unchanged cohort, respectively, based on an inverse probability of treatment weighted approach that adjusting for baseline characteristics of the patients. Multivariate Cox regression analyses showed the two groups had no significant differences in the hazard risk of death, AMI admission, and MACE. Additionally, there was no observed difference in the risk of bleeding, including major or clinically relevant non-major bleeding. The real-world data revealed that de-escalation of P2Y12 inhibitor in DAPT was not associated with a higher risk of death or AMI readmission in Taiwanese patients with AMI undergoing successful PCI.
Collapse
|
16
|
Schilling U, Dingemanse J, Dobrow M, Baumann M, Riederer MA, Juif PE, Ufer M. Insights from In Vitro and Clinical Data to Guide Transition from the Novel P2Y12 Antagonist Selatogrel to Clopidogrel, Prasugrel, and Ticagrelor. Thromb Haemost 2021; 121:755-766. [PMID: 33412611 DOI: 10.1055/s-0040-1721773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Reduced pharmacodynamic (PD) effects of irreversible oral P2Y12 receptor antagonists have been reported when administered during cangrelor infusion. Therefore, the PD interaction liability of the novel P2Y12 receptor antagonist selatogrel with irreversible (i.e., clopidogrel, prasugrel) and reversible (i.e., ticagrelor) oral P2Y12 receptor antagonists was investigated in vitro and in healthy subjects. In vitro, selatogrel reduced the effects of clopidogrel and prasugrel in a concentration-dependent manner, while additive effects were observed for the combination of selatogrel and ticagrelor. Accordingly, a single-center, randomized, double-blind, two-way crossover study was conducted consisting of six groups. In each group (N = 12), an open-label loading dose of 300 or 600 mg clopidogrel, 60 mg prasugrel, or 180 mg ticagrelor was administered 30 minutes (i.e., at t max of selatogrel) or 12 hours after a single subcutaneous dose of 16 mg selatogrel or placebo. Inhibition of platelet aggregation (IPA) was assessed at various time points up to 48 hours. Reduced IPA was determined when clopidogrel or prasugrel was administered 30 minutes after selatogrel (∼40 and 70% lower IPA, respectively, at 24 hours postdosing). However, when administering prasugrel 12 hours after selatogrel, IPA was not impacted (>90% IPA) and in the case of clopidogrel reduced effects were partially mitigated. Similar IPA was determined for ticagrelor when administered 30 minutes after selatogrel or placebo. In conclusion, reduced IPA was observed for clopidogrel and prasugrel when administered after selatogrel, which can be mitigated by applying an appropriate time interval. No PD interaction with ticagrelor was observed.
Collapse
Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | | | - Martine Baumann
- Department of Drug Discovery Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Markus A Riederer
- Department of Drug Discovery Biology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Pierre-Eric Juif
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| |
Collapse
|
17
|
Lee CH, Franchi F, Angiolillo DJ. Clopidogrel drug interactions: a review of the evidence and clinical implications. Expert Opin Drug Metab Toxicol 2020; 16:1079-1096. [PMID: 32835535 DOI: 10.1080/17425255.2020.1814254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with cardiovascular disease are commonly affected by a number of comorbidities leading to a high prevalence of polypharmacy. Polypharmacy increases the probability of drug-drug interactions (DDIs). Amongst these, DDIs involving clopidogrel, the most commonly utilized platelet P2Y12 inhibitor, is a topic of potential clinical concern. AREAS COVERED This article reviews DDIs between clopidogrel and drugs which are widely used in clinical practice. In particular, drugs shown to interfere with the pharmacodynamic and pharmacokinetic effects of clopidogrel and the clinical implications of these findings are reviewed. These drugs include inhibitors of gastric acid secretion, statins, calcium channel blockers, antidiabetic agents, and antimicrobial agents. For the references, we searched PubMed, EMBASE, or the Cochrane Library. EXPERT OPINION Clopidogrel-drug interactions are common. Most of these DDIs are limited to laboratory findings showing an impact on clopidogrel-induced antiplatelet effects. While variability in clopidogrel-induced antiplatelet effects is known to affect clinical outcomes, with high platelet reactivity being associated with thrombotic complications among patients undergoing coronary stenting, most studies assessing the clinical implications of clopidogrel-drug interactions have not shown to significantly affect outcomes. However, awareness of these DDIs remains important for optimizing the selection of concomitant therapies.
Collapse
Affiliation(s)
- Chang Hoon Lee
- Division of Cardiology, University of Florida College of Medicine-Jacksonville , Jacksonville, FL, USA.,Division of Cardiology, Department of Internal Medicine, Veterans Health Service Medical Center , Seoul, Korea
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville , Jacksonville, FL, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville , Jacksonville, FL, USA
| |
Collapse
|
18
|
Calderone D, Capodanno D, Angiolillo DJ. An updated drug profile of ticagrelor with considerations on the treatment of patients with coronary artery disease and diabetes mellitus. Expert Rev Cardiovasc Ther 2020; 18:449-464. [PMID: 32662726 DOI: 10.1080/14779072.2020.1792293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Ticagrelor is an antiplatelet agent acting through direct and reversible competitive inhibition of the platelet P2Y12 receptor. While the clinical merits of ticagrelor in patients who experienced an acute coronary syndrome are widely accepted, its role in stable coronary artery disease is less established. Recently, large-scale trials of ticagrelor have been published in this setting, including a trial in patients with diabetes mellitus (DM). AREAS COVERED This review aims to inform about recent findings on ticagrelor, by appraising the current body of evidence on its use in different clinical scenarios, particularly in DM, ranging from pharmacology to clinical outcomes and future directions. EXPERT OPINION The results of the THEMIS trial, conducted in DM patients with stable coronary artery disease and no prior stroke or myocardial infarction, showed that although ticagrelor in addition to aspirin reduced the risk of ischemic events, this was associated with a parallel increase in bleeding complications. However, patients with history of percutaneous coronary intervention seemed to benefit more from adjunctive ticagrelor therapy. Careful bleeding and ischemic risk stratification remains crucial to define the best antithrombotic strategy for the individual patient.
Collapse
Affiliation(s)
- Dario Calderone
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, FL, USA
| |
Collapse
|
19
|
Giang K, Stallings HE, Clopton P, Stubbs MK, Penny WF. Evaluation of a Novel Antiplatelet Therapy Strategy in Patients Undergoing Elective Percutaneous Coronary Intervention. J Pharm Pract 2020; 34:901-907. [PMID: 32618225 DOI: 10.1177/0897190020933469] [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: 11/15/2022]
Abstract
BACKGROUND Ticagrelor presents less thrombotic risk compared to clopidogrel in acute coronary syndromes. However, its role in dual antiplatelet therapy (DAPT)-naive patients with stable ischemic heart disease (SIHD) undergoing elective percutaneous intervention (PCI) remains unclear, including uncertainty in the method of conversion to clopidogrel for adequate coverage without increased bleeding risk. OBJECTIVE Determine the safety and efficacy of ticagrelor loading and transitioning to clopidogrel in patients with SIHD undergoing elective PCI. METHODS This is a retrospective cohort review of patients with SIHD who underwent elective PCI. The Switch Rx patients were treated with ticagrelor immediately before PCI, converted to clopidogrel 300 mg the day after, and discharged with clopidogrel 75 mg daily. Standard Rx patients, who received a clopidogrel load and received clopidogrel 75 mg daily after the procedure, were analyzed as a matched comparator cohort. The safety outcomes were any bleeding event at 24 hours and 30 days. The efficacy outcomes included major adverse cardiac events (MACE) at 24 hours and 30 days. RESULTS Five Switch Rx patients (n = 54) experienced bleeding academic research consortium type I bleeding within 24 hours, with no subsequent bleeding observed out to 30 days. When comparing the Switch Rx patients (n = 39) to their matched Standard Rx cohort (n = 39), no MACEs occurred within 30 days and there were no significant differences in safety and efficacy outcomes. CONCLUSION In DAPT-naive patients undergoing elective PCI for SIHD, a strategy of in-lab ticagrelor transitioning to clopidogrel with a 300-mg load was not associated with increased bleeding or other adverse events.
Collapse
Affiliation(s)
- Kayla Giang
- Department of Pharmacy Services, VA San Diego Healthcare System, San Diego, CA, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, VA San Diego, University of California, San Diego, CA, USA
| | - Holly E Stallings
- Department of Pharmacy Services, VA San Diego Healthcare System, San Diego, CA, USA
| | - Paul Clopton
- Computational Arrhythmia Research Laboratory, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Maria K Stubbs
- Department of Pharmacy Services, VA San Diego Healthcare System, San Diego, CA, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, VA San Diego, University of California, San Diego, CA, USA
| | - William F Penny
- Division of Cardiology, VA San Diego Healthcare System, San Diego, CA, USA
- School of Medicine, University of California, San Diego, CA, USA
| |
Collapse
|
20
|
Masiero G, Rossini R. De-escalation therapy after acute coronary syndrome: is it reasonable to switch from prasugrel (or ticagrelor) to clopidogrel early? Eur Heart J Suppl 2020; 22:E132-E136. [PMID: 32523457 PMCID: PMC7270966 DOI: 10.1093/eurheartj/suaa078] [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] [Indexed: 11/13/2022]
Abstract
Dual antiplatelet treatment (DAPT) is the treatment of choice to prevent atherothrombotic events in patients with acute coronary syndrome (ACS) treated with percutaneous interventions (PCIs). The availability of different P2Y12 inhibitors set the stage for costum made DAPT, as to achieve the highest profile of safety and efficacy. The de-escalation therapy for the newer and more powerful antiplatelet drugs, such as ticagrelor and prasugrel, to clopidogrel, is a strategy for patients with recent ACS, unfit for continuing DAPT for their high risk of bleeding, or side effects, or socio-economic reasons, but without a prohibitive ischaemic risk. There is a need for compelling clinical evidences able to provide the clinical cardiologist with the necessary information to decide the best antiplatelet strategy for each individual patient.
Collapse
Affiliation(s)
- Giulia Masiero
- USC Cardiologia, Ospedale Santa Croce e Carle, via M. Coppino, 26, Cuneo, Italy
| | - Roberta Rossini
- USC Cardiologia, Ospedale Santa Croce e Carle, via M. Coppino, 26, Cuneo, Italy
| |
Collapse
|
21
|
Franchi F, Rollini F, Rivas J, Rivas A, Agarwal M, Briceno M, Wali M, Nawaz A, Silva G, Shaikh Z, Maailiki N, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Prasugrel Versus Ticagrelor in Patients With CYP2C19 Loss-of-Function Genotypes: Results of a Randomized Pharmacodynamic Study in a Feasibility Investigation of Rapid Genetic Testing. JACC Basic Transl Sci 2020; 5:419-428. [PMID: 32478205 PMCID: PMC7251226 DOI: 10.1016/j.jacbts.2020.02.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/08/2020] [Indexed: 12/22/2022]
Abstract
The feasibility of rapid genetic testing in patients undergoing percutaneous coronary intervention (PCI) and the comparison of the pharmacodynamic effects of prasugrel versus ticagrelor among carriers of cytochrome P450 2C19 loss-of-function alleles treated with PCI has been poorly explored. Rapid genetic testing using the Spartan assay was shown to be feasible and provides results in a timely fashion in a real-world setting of patients undergoing coronary angiography (n = 781). Among patients (n = 223, 28.5%), carriers of at least 1 loss-of-function allele treated with PCI (n = 65), prasugrel, and ticagrelor achieve similar levels of platelet inhibition. (A Pharmacodynamic Study Comparing Prasugrel Versus Ticagrelor in Patients Undergoing PCI With CYP2C19 Loss-of-function [NCT02065479]).
Collapse
Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Jose Rivas
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andrea Rivas
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Malhar Agarwal
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Maryuri Briceno
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Mustafa Wali
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Ahmed Nawaz
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Gabriel Silva
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Zubair Shaikh
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Naji Maailiki
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Latonya Been
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andres M. Pineda
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Siva Suryadevara
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Daniel Soffer
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Martin M. Zenni
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Theodore A. Bass
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | | |
Collapse
|
22
|
Arora S, Shemisa K, Vaduganathan M, Qamar A, Gupta A, Garg SK, Kumbhani DJ, Mayo H, Khalili H, Pandey A, Das SR. Premature Ticagrelor Discontinuation in Secondary Prevention of Atherosclerotic CVD: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 73:2454-2464. [PMID: 31097167 DOI: 10.1016/j.jacc.2019.03.470] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/03/2019] [Indexed: 01/22/2023]
Abstract
Ticagrelor is a cornerstone of modern antithrombotic therapy alongside aspirin in patients with acute coronary syndrome and after percutaneous coronary intervention. Adverse effects such as bleeding and dyspnea have been associated with premature ticagrelor discontinuation, which may limit any potential advantage of ticagrelor over clopidogrel. The randomized trials of ticagrelor captured adverse events, offering the opportunity to more precisely quantify these effects across studies. Therefore, a meta-analysis of 4 randomized clinical trials of ticagrelor conducted between January 2007 and June 2017 was performed to quantify the incidence and causes of premature ticagrelor discontinuation. Among 66,870 patients followed for a median 18 months, premature ticagrelor discontinuation was seen in 25%; bleeding was the most common cause of discontinuation followed by dyspnea. Versus the comparators, the relative risk of dyspnea-related discontinuation during follow-up was 6.4-fold higher, the relative risk of bleeding was 3.2-fold higher, and the relative risk of discontinuation due to any adverse event was 59% higher for patients receiving ticagrelor. Understanding these potential barriers to adherence to ticagrelor is crucial for informed patient-physician decision making and can inform future efforts to improve ticagrelor adherence. This review discusses the incidence, causes, and biological mechanisms of ticagrelor-related adverse effects and offers strategies to improve adherence to ticagrelor.
Collapse
Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kamal Shemisa
- Division of Cardiology, University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Muthiah Vaduganathan
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arman Qamar
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ankur Gupta
- Division of Cardiology, University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Sushil K Garg
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Helen Mayo
- Health Sciences Digital Library and Learning Center, University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Houman Khalili
- Department of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern School of Medicine, Dallas, Texas
| | - Sandeep R Das
- Department of Medicine, Florida Atlantic University, Boca Raton, Florida.
| |
Collapse
|
23
|
Angiolillo DJ, Capodanno D, Danchin N, Simon T, Bergmeijer TO, ten Berg JM, Sibbing D, Price MJ. Derivation, Validation, and Prognostic Utility of a Prediction Rule for Nonresponse to Clopidogrel. JACC Cardiovasc Interv 2020; 13:606-617. [DOI: 10.1016/j.jcin.2020.01.226] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 12/11/2022]
|
24
|
Saito Y, Kobayashi Y. Update on Antithrombotic Therapy after Percutaneous Coronary Intervention. Intern Med 2020; 59:311-321. [PMID: 31588089 PMCID: PMC7028427 DOI: 10.2169/internalmedicine.3685-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/26/2019] [Indexed: 02/06/2023] Open
Abstract
Percutaneous coronary intervention (PCI) has become a standard-of-care procedure in the setting of angina or acute coronary syndrome. Antithrombotic therapy is the cornerstone of pharmacological treatment aimed at preventing ischemic events following PCI. Dual antiplatelet therapy as the combination of aspirin and P2Y12 inhibitor has been proven to decrease stent-related thrombotic risks. However, the optimal duration of dual antiplatelet therapy, an appropriate P2Y12 inhibitor, and the choice of aspirin versus P2Y12 inhibitor as single antiplatelet therapy remain controversial. Furthermore, the combined use of oral anticoagulation in addition to antiplatelet therapy is a complex issue in clinical practice, such as in patients with atrial fibrillation. The key challenge concerning the optimal antithrombotic regimen is ensuring a balance between protection against thrombotic events and against excessive increases in bleeding risk. In this review article, we summarize the current evidence concerning antithrombotic therapy in patients with coronary artery disease undergoing PCI.
Collapse
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
- Yale School of Medicine, USA
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Japan
| |
Collapse
|
25
|
Crimi G, Morici N, Ferrario M, Ferri LA, Piatti L, Grosseto D, Cacucci M, Mandurino Mirizzi A, Toso A, Piscione F, De Carlo M, Elia LR, Trimarco B, Bolognese L, Bovenzi FM, De Luca G, Savonitto S, De Servi S. Time Course of Ischemic and Bleeding Burden in Elderly Patients With Acute Coronary Syndromes Randomized to Low-Dose Prasugrel or Clopidogrel. J Am Heart Assoc 2020; 8:e010956. [PMID: 30636561 PMCID: PMC6497351 DOI: 10.1161/jaha.118.010956] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elderly patients have high ischemic and bleeding rates after acute coronary syndrome; however, the occurrence of these complications over time has never been studied. This study sought to characterize average daily ischemic rates ( ADIRs ) and average daily bleeding rates ( ADBRs ) over 1 year in patients aged >74 years with acute coronary syndrome undergoing percutaneous coronary intervention who were randomized in the Elderly ACS 2 trial, comparing low-dose prasugrel (5 mg daily) with clopidogrel (75 mg daily). Methods and Results ADIRs and ADBRs were calculated as the total number of events, including recurrent events, divided by the number of patient-days of follow-up and assessed within different clinical phases: acute (0-3 days), subacute (4-30 days), and late (31-365 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparisons of ADIRs and ADBRs and the pairwise comparison of clopidogrel versus prasugrel effects. Globally, ADIRs were 2.6 times (95% CI, 2.4-2.9) higher than ADBRs . ADIRs were significantly higher in the clopidogrel arm than in the low-dose prasugrel arm in the subacute phase ( Padj<0.001) without a difference in ADBRs ( Padj=0.35). In the late phase, ADIRs remained significantly higher with clopidogrel ( Padj<0.001), whereas ADBRs were significantly higher with low-dose prasugrel ( Padj<0.001). Conclusions Ischemic burden was greater than bleeding burden in all clinical phases of 1-year follow-up of elderly patients with acute coronary syndrome treated with percutaneous coronary intervention. Low-dose prasugrel reduced ischemic events in the subacute and chronic phases compared with clopidogrel, whereas bleeding burden was lower with clopidogrel in the late phase. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01777503.
Collapse
Affiliation(s)
- Gabriele Crimi
- 1 Division of Cardiology IRCCS Fondazione Policlinico S. Matteo Pavia Italy
| | - Nuccia Morici
- 2 First Division of Cardiology Ospedale Niguarda Milano Italy
| | - Maurizio Ferrario
- 1 Division of Cardiology IRCCS Fondazione Policlinico S. Matteo Pavia Italy
| | - Luca A Ferri
- 3 Division of Cardiology Ospedale Manzoni Lecco Italy
| | - Luigi Piatti
- 3 Division of Cardiology Ospedale Manzoni Lecco Italy
| | | | | | | | - Anna Toso
- 6 Division of Cardiology Ospedale S. Stefano Prato Italy
| | - Federico Piscione
- 7 Department of Medicine, Surgery and Dentistry-Schola Medica Salernitana University of Salerno Italy
| | - Marco De Carlo
- 8 Cardiac Catheterization Laboratory Cardiothoracic and Vascular Department Azienda Ospedaliero-Universitaria Pisana Pisa Italy
| | - Luigi Raffaele Elia
- 9 Division of Cardiology and Intensive Care Unit Ospedale Cardarelli Napoli Italy
| | - Bruno Trimarco
- 10 Division of Cardiology Policlinico Universitario Federico II Napoli Italy
| | | | | | - Giuseppe De Luca
- 13 Division of Cardiology Azienda Ospedaliera-Universitaria "Maggiore della Carità" Eastern Piedmont University Novara Italy
| | | | | |
Collapse
|
26
|
Lattuca B, Silvain J, Yan Y, Pouillot C, Cuisset T, Cayla G, Henry P, Diallo A, Elhadad S, Rangé G, Lhermusier T, Boueri Z, Motreff P, Carrié D, Vicaut E, Montalescot G, Collet JP. Reasons for the Failure of Platelet Function Testing to Adjust Antiplatelet Therapy: Pharmacodynamic Insights From the ARCTIC Study. Circ Cardiovasc Interv 2019; 12:e007749. [PMID: 31694410 DOI: 10.1161/circinterventions.118.007749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the ARCTIC trial (Assessment by a Double Randomization of a Conventional Antiplatelet Strategy Versus a Monitoring-Guided Strategy for Drug-Eluting Stent Implantation and of Treatment Interruption Versus Continuation One Year After Stenting), treatment adjustment following platelet function testing failed to improve clinical outcomes. However, high-on-treatment platelet reactivity (HPR) is considered as a predictor of poor ischemic outcome. This prespecified substudy evaluated clinical outcomes according to the residual platelet reactivity status after antiplatelet therapy adjustment. METHODS We analyzed the 1213 patients assigned to the monitoring arm of the ARCTIC trial in whom platelet reactivity was evaluated by the VerifyNow P2Y12 test before percutaneous coronary intervention and during the maintenance phase (at 14 days). HPR was defined as platelet reaction unit≥235U. The primary ischemic end point, a composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization and the safety end point of major bleeding were assessed according to the platelet reactivity status. RESULTS Before percutaneous coronary intervention, 35.7% of patients displayed HPR (n=419). During the acute phase, between percutaneous coronary intervention and the 14-day platelet function testing, ischemic (adjusted hazard ratio, 0.94 [95% CI, 0.74-1.18]; P=0.58) and safety outcomes (hazard ratio, 1.28 [95% CI, 0.22-7.59]; P=0.78) were similar in HPR and non-HPR patients. During the maintenance phase, the proportion of HPR patients (n=186, 17.4%) decreased by 56%. At 1-year, there was no difference for the ischemic end point (5.9% versus 6.0%; adjusted hazard ratio, 0.79 [95% CI, 0.40-1.58]; P=0.51) and a nonsignificant higher rate of major bleedings (2.7% versus 1.0%, hazard ratio, 2.83 [95% CI, 0.96-8.41]; P=0.06) in HPR versus non-HPR patients. CONCLUSIONS The proportion of HPR was halved after platelet function testing and treatment adjustment but without significant ischemic benefit at 1 year. HPR seems more as a modifiable risk marker than a risk factor of ischemic outcome. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00827411.
Collapse
Affiliation(s)
- Benoit Lattuca
- Sorbonne University, ACTION Study Group, INSERM UMRS 1166, Cardiology Institute, Pitié-Salpêtrière (AP-HP) University Hospital, Paris, France (B.L., J.S., Y.Y., G.M., J.-P.C.).,Cardiology Department, Caremeau University Hospital, ACTION Study Group, Montpellier University, Nîmes, France (B.L., G.C.)
| | - Johanne Silvain
- Sorbonne University, ACTION Study Group, INSERM UMRS 1166, Cardiology Institute, Pitié-Salpêtrière (AP-HP) University Hospital, Paris, France (B.L., J.S., Y.Y., G.M., J.-P.C.)
| | - Yan Yan
- Sorbonne University, ACTION Study Group, INSERM UMRS 1166, Cardiology Institute, Pitié-Salpêtrière (AP-HP) University Hospital, Paris, France (B.L., J.S., Y.Y., G.M., J.-P.C.).,Emergency and Critical Care Center, Beijing Anzhen Hospital, Capital Medical University, China (Y.Y.)
| | - Christophe Pouillot
- Cardiology Department, Sainte Clotilde Clinic, St. Denis de la Réunion, France (C.P.)
| | - Thomas Cuisset
- ACTION Study Group, Cardiology Department, La Timone Hospital, Marseille, France (T.C.)
| | - Guillaume Cayla
- Cardiology Department, Caremeau University Hospital, ACTION Study Group, Montpellier University, Nîmes, France (B.L., G.C.)
| | - Patrick Henry
- Cardiology Department (P.H.), Lariboisière University Hospital, Paris, France
| | - Abdourahmane Diallo
- ACTION Study Group, Epidemiology and Clinic Research Unit (A.D., E.V.), Lariboisière University Hospital, Paris, France
| | - Simon Elhadad
- Cardiology department, Lagny-Marne la Vallée Hospital, France (S.E.)
| | - Grégoire Rangé
- Cardiology department, Chartres Hospital, Le Coudray, France (G.R.)
| | - Thibault Lhermusier
- Cardiology Department, Rangueil University Hospital, Toulouse, France (T.L., D.C.)
| | - Ziad Boueri
- Cardiology Department, Bastia Hospital, France (Z.B.)
| | - Pascal Motreff
- Cardiology Department, Gabriel Montpied University Hospital, Clermont-Ferrand, France (P.M.)
| | - Didier Carrié
- Cardiology Department, Rangueil University Hospital, Toulouse, France (T.L., D.C.)
| | - Eric Vicaut
- ACTION Study Group, Epidemiology and Clinic Research Unit (A.D., E.V.), Lariboisière University Hospital, Paris, France
| | - Gilles Montalescot
- Sorbonne University, ACTION Study Group, INSERM UMRS 1166, Cardiology Institute, Pitié-Salpêtrière (AP-HP) University Hospital, Paris, France (B.L., J.S., Y.Y., G.M., J.-P.C.)
| | - Jean-Philippe Collet
- Sorbonne University, ACTION Study Group, INSERM UMRS 1166, Cardiology Institute, Pitié-Salpêtrière (AP-HP) University Hospital, Paris, France (B.L., J.S., Y.Y., G.M., J.-P.C.)
| |
Collapse
|
27
|
Yao Y, Wang P, Wang XZ, Zhao X, Zhao W, Zhou TN, Zhang L. Optimal strategy of switching from clopidogrel to ticagrelor in Chinese acute coronary syndrome patients with complicated coronary artery disease: the switching from clopidogrel to ticagrelor (SHIFT-CACS) study. Chin Med J (Engl) 2019; 132:2292-2299. [PMID: 31567375 PMCID: PMC6819042 DOI: 10.1097/cm9.0000000000000444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The dose and time point for switching from clopidogrel to ticagrelor remain controversial, especially for Chinese acute coronary syndrome (ACS) patients with complicated coronary artery disease (CAD). Hence, the purpose of this study was to further explore the optimal dose and time point for the switching strategy to balance the increase in platelet inhibition and the decrease in adverse events in Chinese ACS patients with complicated CAD managed by percutaneous coronary intervention (PCI). METHODS From July 2017 to December 2017, the prospective, randomized, open-label study (the SwitcHIng from clopidogrel to ticagrelor study) assigned the eligible Chinese ACS patients with complicated CAD managed by PCI (n = 102) for 90 mg of ticagrelor at 12 h (T-90 mg-12 h), 90 mg of ticagrelor at 24 h (T-90 mg-24h) or 180 mg ticagrelor at 24 h (T-180 mg-24 h) after the last dose of clopidogrel. The primary endpoint was the comparison of maximal platelet aggregation (MPA) values at 2 h after switching strategies among the three groups. In addition, the MPA values at baseline, 8 h and before discharge and the rates of high on-treatment platelet reactivity were evaluated, the incidences of bleeding episodes and dyspnea during hospitalization and at 30-day follow-up in our study were also recorded. The MPA was measured by light transmittance aggregometry in our study. A repeated-measures analysis of variance (ANOVA) model and one-way ANOVA were used to compare data for the primary endpoint. RESULTS The MPA values were significantly decreased in the T-180 mg-24 h group compared with the T-90 mg-12 h group (P = 0.017) and decreased numerically compared with the T-90 mg-24 h group (P = 0.072) at 2 h. In particular, the MPA values were markedly reduced in the T-90 mg-24 h group compared with the T-90 mg-12 h group at 8 h after switching treatment (P = 0.002). There was no significant difference among the three groups in all bleedings and dyspnea events. CONCLUSIONS The optimal treatment strategy recommended in this study for Chinese ACS patients with complicated CAD managed by PCI is 180 or 90 mg of ticagrelor at 24 h after the last dose of clopidogrel. In addition, a negative interaction was detected in this study between the overlap for clopidogrel and ticagrelor at 12 h after the last dose of clopidogrel. TRIAL REGISTRATION ClinicalTrials.gov, NCT03577652; http://clinicaltrials.gov/ct2/show/NCT03577652.
Collapse
Affiliation(s)
- Ying Yao
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
- Department of Clinical Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, China
| | - Ping Wang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
- Department of Clinical Pharmacy, Shenyang Pharmaceutical University, Shenyang, Liaoning 110016, China
| | - Xiao-Zeng Wang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
| | - Xin Zhao
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
| | - Wei Zhao
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
| | - Tie-Nan Zhou
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
| | - Lei Zhang
- Department of Cardiology, Institute of Cardiovascular Research, General Hospital of Northern Theater Command, Shenyang, Liaoning 110840, China
| |
Collapse
|
28
|
Dhillon AS, Caro J, Tun H, Armstrong DG, Rowe V, Shavelle DM, Clavijo LC. Therapeutic Window of Clopidogrel and Ticagrelor in Patients With Critical Limb-Threatening Ischemia. J Cardiovasc Pharmacol Ther 2019; 25:158-163. [PMID: 31550912 DOI: 10.1177/1074248419877411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Critical limb-threatening ischemia (CLTI) is associated with an increased risk of major adverse limb events and mortality. High on-treatment platelet reactivity (HPR) is associated with an increased risk of ischemic events, while low on-treatment platelet reactivity (LPR) is associated with an increased risk of bleeding. This study investigates the frequency with which patients with CLTI on clopidogrel or ticagrelor achieve a "therapeutic window" (TW) of platelet inhibition. METHODS Data from the "Switch To Ticagrelor in Critical Limb Ischemia Anti-Platelet Study" were assessed retrospectively to determine the incidence of TW of on-treatment platelet reactivity in 50 consecutive patients with CLTI (mean age: 65.2 ± 10.5 years, 54% male). The data included 4 measurements of patients' platelet reactivity using the VerifyNow P2Y12 Assay: baseline and steady state platelet reactivity on clopidogrel 75 mg daily and on ticagrelor 90 mg twice daily. RESULTS At baseline, 46% of patients on clopidogrel were within TW of on-treatment platelet reactivity compared to 10% of patients on ticagrelor (P < .0001). At steady state, 42% of patients on clopidogrel were within the TW compared to 10% of patients on ticagrelor (P < .0001). Patients on ticagrelor exhibited higher rates of LPR compared to those on clopidogrel at baseline as well as at steady state (baseline 88% vs 18%, steady state 88% vs 28%; P < .0001). CONCLUSION Although ticagrelor has been proposed as an alternative for patients with HPR on clopidogrel, the current study observes an excess of platelet inhibition with ticagrelor in most patients with CLTI at a dose of 90 mg twice daily.
Collapse
Affiliation(s)
- Ashwat S Dhillon
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jorge Caro
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Han Tun
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David G Armstrong
- Division of Vascular Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Vincent Rowe
- Division of Vascular Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David M Shavelle
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Leonardo C Clavijo
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
29
|
Capranzano P, Francaviglia B, Angiolillo DJ. Pharmacodynamics During Transition Between Platelet P2Y 12 Inhibiting Therapies. Interv Cardiol Clin 2019; 8:321-340. [PMID: 31445718 DOI: 10.1016/j.iccl.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Several platelet P2Y12 inhibiting agents, both oral and intravenous, are available for clinical use. The oral P2Y12 inhibitors comprise clopidogrel, prasugrel, and ticagrelor. Cangrelor is the only intravenous P2Y12 inhibitor. Numerous pharmacodynamic studies have been performed to assess the impact of P2Y12 inhibitor switching on platelet reactivity profiles and to define the optimal strategy if switching is needed, with the goal of minimizing the risk of having inadequate platelet inhibition due to potential drug-drug interactions occurring during the drug overlap phase. This article provides an overview of pharmacodynamic studies assessing switching between P2Y12 inhibitors and recommendations on switching modalities based on these findings.
Collapse
Affiliation(s)
- Piera Capranzano
- Division of Cardiology, CAST Policlinico Hospital, University of Catania, S. Sofia n. 78, Catania 95123, Italy.
| | - Bruno Francaviglia
- Division of Cardiology, CAST Policlinico Hospital, University of Catania, S. Sofia n. 78, Catania 95123, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th floor, 655 West 8th Street, Jacksonville, FL 32209, USA
| |
Collapse
|
30
|
Franchi F, Rollini F, Park Y, Hu J, Kureti M, Rivas Rios J, Faz G, Yaranov D, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Effects of Methylnaltrexone on Ticagrelor-Induced Antiplatelet Effects in Coronary Artery Disease Patients Treated With Morphine. JACC Cardiovasc Interv 2019; 12:1538-1549. [PMID: 31377269 DOI: 10.1016/j.jcin.2019.05.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/17/2019] [Accepted: 05/20/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to assess if intravenous methylnaltrexone can counteract the effects of morphine on the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of ticagrelor. BACKGROUND Morphine delays the onset of action of oral P2Y12 receptor inhibitors, including ticagrelor, by inhibiting gastric emptying and leading to delayed drug absorption. Methylnaltrexone is a peripheral opioid receptor antagonist that has the potential to prevent opioid-induced peripherally mediated side effects (e.g., gastric emptying inhibition) without affecting analgesia. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover study, aspirin-treated patients with stable coronary artery disease (n = 30) were randomized to receive methylnaltrexone (0.3 mg/kg intravenous) or matching placebo. After methylnaltrexone or placebo administration, all patients received morphine (5 mg intravenous). This was followed 15 min later by a 180-mg loading dose of ticagrelor. Patients crossed over to the alternative study treatment after 7 ± 2 days of washout. PK and PD assessments were performed at 12 time points (6 pre- and 6 post-crossover). PK analysis included measurement of plasma levels of ticagrelor and its major active metabolite (AR-C124910XX). PD assessments included VerifyNow P2Y12, light transmittance aggregometry, and vasodilator-stimulated phosphoprotein. RESULTS Only marginal changes in plasma levels of ticagrelor (and its major active metabolite) were observed with ticagrelor: maximum plasma concentration and area under the plasma concentration versus time curve from time 0 to the last measurable concentration were 38% and 30% higher, respectively, in patients receiving methylnaltrexone compared with those receiving placebo, but no differences in time to maximum plasma concentration were observed. There were no differences in P2Y12 reaction units by VerifyNow P2Y12 between groups at each time point, including 2 h (the primary endpoint; p = 0.261). Similarly, there were no differences in PD markers assessed by light transmittance aggregometry and vasodilator-stimulated phosphoprotein. CONCLUSIONS In patients with coronary artery disease receiving morphine, intravenous administration of the peripheral opioid receptor antagonist methylnaltrexone leads to only marginal changes in plasma levels of ticagrelor and its major metabolite, without affecting levels of platelet reactivity. (Effect of Methylnaltrexone on the PK/PD Profiles of Ticagrelor in Patients Treated With Morphine; NCT02403830).
Collapse
Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Yongwhi Park
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Jenny Hu
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Megha Kureti
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Jose Rivas Rios
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Gabriel Faz
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Dmitry Yaranov
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Latonya Been
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andres M Pineda
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Siva Suryadevara
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Daniel Soffer
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Martin M Zenni
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Theodore A Bass
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | | |
Collapse
|
31
|
Angiolillo DJ, Patti G, Chan KT, Han Y, Huang WC, Yakovlev A, Paek D, Del Aguila M, Girotra S, Sibbing D. De-escalation from ticagrelor to clopidogrel in acute coronary syndrome patients: a systematic review and meta-analysis. J Thromb Thrombolysis 2019; 48:1-10. [PMID: 31004312 PMCID: PMC6556170 DOI: 10.1007/s11239-019-01860-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2-28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1-4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4-4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation.
Collapse
Affiliation(s)
- Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, ACC Building 5th floor, 655 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Giuseppe Patti
- Chair of Cardiology, University of L'Aquila, Via Camponeschi, 19, L'Aquila, Italy
| | - Kam Tim Chan
- Director of Cardiac Catheterization and Interventional Laboratory, Consultant Cardiologist, Queen Elizabeth Hospital, 30 Gascoigne Rd, King's Park, Hong Kong, Hong Kong
| | - Yaling Han
- Department of Cardiology, The General Hospital of Shenyang Military Region, 83 Wenhua Rd, Shenhe District, Shenyang City, Liaoning, China
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386 Dazhong 1st Road, Zuoying District, Kaohsiung City, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Alexey Yakovlev
- Almazov National Medical Research Centre, 12 Mayakovsky St, Saint Petersburg, Russia
| | - Dara Paek
- Doctor Evidence, 301 Arizona Ave #301, Santa Monica, CA, USA
| | | | - Shalini Girotra
- Sanofi, General Medicine and Emerging Markets, 38 Beach Road, Singapore, Singapore
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Marchioninistraße 15, 81377, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| |
Collapse
|
32
|
Arps K, Pallazola VA, Cardoso R, Meyer J, Jones R, Latina J, Gluckman TJ, Stone NJ, Blumenthal RS, McEvoy JW. Clinician's Guide to the Updated ABCs of Cardiovascular Disease Prevention: A Review Part 1. Am J Med 2019; 132:e569-e580. [PMID: 30710541 DOI: 10.1016/j.amjmed.2019.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 01/17/2023]
Abstract
Efforts to better control risk factors for cardiovascular disease and prevent the development of subsequent events are crucial to maintaining healthy populations. In today's busy practice environment and with the overwhelming pace of new research findings, ensuring appropriate emphasis and implementation of evidence-based preventive cardiovascular care can be challenging. The ABCDEF approach to cardiovascular disease prevention is intended to improve dissemination of contemporary best practices and facilitate the implementation of comprehensive preventive strategies for clinicians. This review serves as a succinct yet authoritative overview for internists and subspecialty cardiologists not otherwise focused on cardiovascular prevention. The goal of this 2-part series is to compile a state-of-the-art list of elements central to both primary and secondary prevention of cardiovascular disease, using an ABCDEF checklist, with particular focus on recent society guideline updates. In Part 1 we highlight developments in cardiovascular risk assessment tools, summarize important recent aspirin trials, discuss prevention considerations in atrial fibrillation, and review guidelines for blood pressure categorization, goals, and therapy.
Collapse
Affiliation(s)
- Kelly Arps
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md.
| | - Vincent A Pallazola
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Rhanderson Cardoso
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Joseph Meyer
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Richard Jones
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Jacqueline Latina
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Portland, Ore
| | - Neil J Stone
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md
| | - John W McEvoy
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Md; National Institute for Preventive Cardiology and National University of Ireland, Galway
| |
Collapse
|
33
|
De-escalation of anti-platelet therapy in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a narrative review. Chin Med J (Engl) 2019; 132:197-210. [PMID: 30614864 PMCID: PMC6365275 DOI: 10.1097/cm9.0000000000000047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention (PCI). In current clinical situation, availability of different oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) has enabled physicians to switch among therapies owing to specific clinical scenarios. Although optimum time, loading dose and interval of transition between P2Y12 inhibitors is still controversial and needs further evidence, switching between oral inhibitors frequently occurs in clinical practice for several reasons. Data sources: This review was based on data in articles published in PubMed up to June 2018, with the following keywords “antiplatelet therapy”, “ACS”, “PCI”, “ticagrelor”, and “clopidogrel”. Study selection: Original articles and critical reviews on de-escalation strategy in ACS patients after PCI were selected. References of the retrieved articles were also screened to search for potentially relevant papers. Results: Safety concerns associated with switching between antiplatelet agents, has prompted the use of clopidogrel for patients with ACS especially after PCI as a de-escalation strategy. Practical considerations for de-escalating therapies in patients with ACS such as reducing dose of P2Y12 inhibitors or shortening duration of DAPT (followed by aspirin or P2Y12 receptor inhibitor monotherapy) as potential options are yet to be standardized and validated. Conclusions: Current review will provide an overview of the pharmacology of common P2Y12 inhibitors, definitions of de-escalation and different de-escalating strategies and its outcomes, along with possible direction to be explored in de-escalation.
Collapse
|
34
|
Carrillo-Aleman L, Marín F, Rivera-Caravaca JM, Vicente-Ibarra N, Candela-Sanchez E, Esteve-Pastor MA, Lozano T, Sandín-Rollan M, Pernias-Escrig V, Macías M, Quintana-Giner M, Veliz A, Orenes-Piñero E, Martínez-Martínez JG, Ruiz-Nodar JM. Switching of Oral P2Y 12 Inhibitor Treatment in Patients with Acute Coronary Syndrome: Prevalence, Predictors, and Prognosis. Clin Drug Investig 2019; 39:275-283. [PMID: 30623372 DOI: 10.1007/s40261-018-0736-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Dual antiplatelet therapy is one of the main treatments in acute coronary syndrome (ACS). Switching antiplatelet agents may be necessary in some patients to improve efficacy or safety. The objective of this study was to determine the prevalence, predictors, and implications of clinical switching in patients during hospital admission and 1-year follow-up at discharge. METHODS Observational, prospective, multicenter registry study in patients discharged following an admission for ACS and followed up for 1 year. We analyzed ischemic and bleeding events as well as treatment changes. RESULTS We recruited 1717 patients; in-hospital switching occurred in 425 (24.8%): 15.1% to clopidogrel and 84.9% to newer antiplatelet drugs (prasugrel or ticagrelor). Those switched to newer antiplatelets were younger, with lower scores on the GRACE and CRUSADE scales, admitted more frequently for ST-elevation myocardial infarction and underwent more invasive management and percutaneous revascularization. The clinical cardiologist was responsible for most in-hospital switching to newer antiplatelets (79.6%). The loading dose of the second antiplatelet did not affect incidence of bleeding events. Post-discharge switching was infrequent (2%) and depended mainly on clinical indications; only 30% was related to a new ACS. CONCLUSIONS In a contemporary registry with ACS, in-hospital switching of antiplatelet drugs was frequent. Those switched to newer antiplatelets were younger and admitted more frequently for ST-elevation myocardial infarction. Post-discharge switching was infrequent.
Collapse
Affiliation(s)
- Luna Carrillo-Aleman
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain.
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - José M Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Nuria Vicente-Ibarra
- Department of Cardiology, Hospital General Universitario de Elche, Alicante, Spain
| | - Elena Candela-Sanchez
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | | | - Teresa Lozano
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Miriam Sandín-Rollan
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Vicente Pernias-Escrig
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Manuel Macías
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Miriam Quintana-Giner
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Andrea Veliz
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Esteban Orenes-Piñero
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Juan G Martínez-Martínez
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Juan M Ruiz-Nodar
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| |
Collapse
|
35
|
Capranzano P, Capodanno D. Switching between P2Y 12 inhibitors: Rationale, methods, and expected consequences. Vascul Pharmacol 2019; 116:4-7. [PMID: 30876967 DOI: 10.1016/j.vph.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/19/2019] [Accepted: 03/03/2019] [Indexed: 10/27/2022]
Abstract
The pharmacological and clinical differences of the three recommended oral P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) enable physicians to switch from one agent to another that it is considered more appropriate in the specific clinical setting. Moreover, the recent availability of cangrelor, the only intravenous P2Y12 inhibitor with a rapid onset and offset of its antiplatelet action, makes it necessary to switch from this agent to an oral P2Y12 inhibitor for a continued platelet inhibition after percutaneous coronary intervention. Several pharmacodynamic studies have provided information on how to change drug, in terms of timing and dosage, without running the risk of a temporary impairment of platelet inhibition. In addition, several studies have assessed the impact of the switching between P2Y12 inhibitors on clinical outcomes. Overall, these evidences have prompted the development of an extensive expert consensus document, have set the basis for recent practice guidelines recommendations, and have stimulated several systematic overviews. The present article provides a brief and schematic summary on the topic of switching between P2Y12 inhibitors, focusing on three main practical issues: why and how to switch therapies and what are the clinical consequences of such strategy.
Collapse
Affiliation(s)
- Piera Capranzano
- Cardiology Division, CAST Policlinico Hospital, University of Catania, Catania, Italy.
| | - Davide Capodanno
- Cardiology Division, CAST Policlinico Hospital, University of Catania, Catania, Italy
| |
Collapse
|
36
|
Guo C, Li M, Lv YH, Zhang MB, Wang ZL. De-escalation versus standard dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Platelets 2019; 31:15-25. [DOI: 10.1080/09537104.2019.1574969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Chen Guo
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Min Li
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yong-Hui Lv
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Ming-Bo Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Zhi-Lu Wang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| |
Collapse
|
37
|
Alexopoulos D, Lianos I, Vlachakis P, Sfantou D, Dragona VM, Varlamos C. De-Escalation of Treatment With Oral P2Y12 Receptor Inhibitors: Current Status and Perspectives. J Cardiovasc Pharmacol Ther 2019; 24:304-314. [DOI: 10.1177/1074248418823724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panagiotis Vlachakis
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Danai Sfantou
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vassiliki-Maria Dragona
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalambos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| |
Collapse
|
38
|
Angiolillo DJ. Switching antiplatelet therapy in real-world clinical practice. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:897-898. [PMID: 30551835 DOI: 10.1016/j.carrev.2018.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
39
|
Kheiri B, Osman M, Abdalla A, Chahine A, Ahmed S, Osman K, Bachuwa G, Hassan M, Bhatt DL. De-Escalation of Antiplatelet Therapy in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Clinical Trials. J Cardiovasc Pharmacol Ther 2018; 24:153-159. [PMID: 30419754 DOI: 10.1177/1074248418809098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIMS Patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI) are recommended to be placed on potent P2Y12 blockade. However, the long-term bleeding risk is high. Therefore, despite no definitive evidence, switching to clopidogrel beyond the acute phase is common. We aimed to evaluate the clinical outcomes of antiplatelet de-escalation compared with continuation in patients treated with PCI. METHODS We searched databases for randomized clinical trials (RCTs) that evaluated the safety and efficacy of antiplatelet de-escalation compared with continuation in patients treated with PCI. Pooled summary estimates were calculated. RESULTS We included 3 RCTs with 3391 patients (median follow-up: 12 months). Compared with the continued group, the net clinical outcome (composite of bleeding or thrombotic events) was significantly reduced in the group switched to clopidogrel (8.7% vs 12.1%; risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.43-0.97; P = .03). However, there were similar clinical outcomes between groups for major adverse cardiovascular events (MACE; RR: 0.78; 95% CI: 0.55-1.11; P = .17), all Bleeding Academic Research Consortium (BARC) types bleeding (RR: 0.61; 95% CI: 0.33-1.11; P = .10), or BARC types ≥2 bleeding (RR: 0.49; 95% CI: 0.19-1.26; P = .14). CONCLUSIONS Our results suggest a net clinical benefit of de-escalation therapy shortly after PCI, without increased risk of MACE. Larger randomized trials will be necessary to confirm these findings.
Collapse
Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mohammed Osman
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ahmed Abdalla
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Adam Chahine
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Sahar Ahmed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Khansa Osman
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Mustafa Hassan
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
40
|
Li X, Su G, Wang G, Hu H, Fan C. Switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction undergoing successful percutaneous coronary intervention in real-world China: Occurrences, reasons, and long-term clinical outcomes. Clin Cardiol 2018; 41:1446-1454. [PMID: 30225843 PMCID: PMC6490115 DOI: 10.1002/clc.23074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/29/2018] [Accepted: 09/09/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although switching between ticagrelor and clopidogrel is common in clinical practice, the efficacy and safety of this de-escalation remain controversial. HYPOTHESIS We assessed the occurrences, reasons, and outcomes of switching from ticagrelor to clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing successful primary percutaneous coronary intervention (PCI). METHODS A total of 653 patients with STEMI were randomly assigned to receive loading dose of ticagrelor or clopidogrel before PCI and then received maintenance dose, respectively, for 12 months follow-up. The primary outcome was major adverse cardiac events (MACE), including cardiovascular death, nonfatal myocardial infarction, and stroke. The secondary outcome included unexpected rehospitalization for angina, coronary revascularization, and stent thrombosis. The safety outcome was bleeding described by the Bleeding Academic Research Consortium (BARC) criteria. RESULTS A total of 602 participants completed the study. The rate of switching from ticagrelor to clopidogrel was 48.6% and the main reason was financial burden. The rate of secondary ischemic events in the de-escalation group was higher than that in the ticagrelor group (15.1% vs 5.6%, P = 0.008), but lower than that in the clopidogrel group (15.1% vs 24.6%, P = 0.03), while there were no significant differences in MACE among the three groups (P = 0.16). De-escalation, ticagrelor, and clopidogrel did not cause significant differences in the rates of major bleeding among the three groups (BARC ≥ 2, P = 0.34). CONCLUSION Switching from ticagrelor to clopidogrel is very common in patients with STEMI in China. De-escalation might be safe but associated with high risk of ischemic events as compared to ticagrelor.
Collapse
Affiliation(s)
- Xin‐Yun Li
- Department of CardiologyJinan Central Hospital Affiliated to Shandong UniversityShangdongChina
| | - Guo‐Hai Su
- Department of CardiologyJinan Central Hospital Affiliated to Shandong UniversityShangdongChina
| | - Guang‐Xin Wang
- Department of CardiologyJinan Central Hospital Affiliated to Shandong UniversityShangdongChina
| | - Hong‐Yan Hu
- Department of CardiologyJinan Central Hospital Affiliated to Shandong UniversityShangdongChina
| | - Chun‐Jie Fan
- Department of CardiologyJinan Central Hospital Affiliated to Shandong UniversityShangdongChina
| |
Collapse
|
41
|
Liu L, Liao H, Zhong S, Liu Y, Xiao C. Effects of switching ticagrelor to clopidogrel on cardiovascular outcomes in patients with acute coronary syndrome. Medicine (Baltimore) 2018; 97:e13381. [PMID: 30508934 PMCID: PMC6283150 DOI: 10.1097/md.0000000000013381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Present study was to evaluate whether switching ticagrelor to clopidogrel would impact platelet reactivity and cardiovascular outcomes in acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI).A total of 202 ACS patients after PCI were enrolled and prescribed ticagrelor. Before discharge, 138 (68%) patients were switched to clopidogrel. Peripheral blood was obtained before switching and at 48 hours after switching to measure platelet reactivity. Patients were followed for 30 days to evaluate cardiovascular events.Compared to ticagrelor group, patients in clopidogrel group were more likely to be male (69.6% vs 65.6%), smokers (34.1% vs 31.3%) and had higher prevalence of hypertension (75.4% vs 71.9%). The frequency of right coronary artery lesion was significantly higher in ticagrelor group (34.4% vs 30.4%). There were no significant differences in baseline platelet reactivity (37.6 ± 5.2% vs 38.4 ± 4.9%). Forty-eight hours after switching to clopidogrel, platelet reactivity in clopidogrel group was significantly higher (46.3 ± 5.6% vs 38.1 ± 5.0%, P <.05). Patients in clopidogrel group had significantly higher incidence of cardiovascular events (3.6% vs 1.6%, P <.05). However, after further adjusted for platelet reactivity at 48 hours of switching, clopidogrel switching was not significantly associated with composite outcomes, with hazard ratio 1.08 (95% confidence interval 0.98-1.21, P = .063), indicating that platelet reactivity was a critical mediator between antiplatelet drug switching and cardiovascular outcomes.ACS patients after PCI treatment, early switching ticagrelor to clopidogrel results in increased platelet reactivity and higher incidence of short-term cardiovascular events.
Collapse
|
42
|
Orme RC, Parker WA, Thomas MR, Judge HM, Baster K, Sumaya W, Morgan KP, McMellon HC, Richardson JD, Grech ED, Wheeldon NM, Hall IR, Iqbal J, Barmby D, Gunn JP, Storey RF. Study of Two Dose Regimens of Ticagrelor Compared With Clopidogrel in Patients Undergoing Percutaneous Coronary Intervention for Stable Coronary Artery Disease. Circulation 2018; 138:1290-1300. [PMID: 29930021 PMCID: PMC6159686 DOI: 10.1161/circulationaha.118.034790] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/07/2018] [Accepted: 06/05/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Ticagrelor has superior efficacy to clopidogrel in the management of acute coronary syndromes but has not been assessed in patients undergoing percutaneous coronary intervention for stable coronary artery disease. We compared the pharmacodynamic effects of ticagrelor and clopidogrel in this stable population. METHODS One hundred eighty aspirin-treated stable coronary artery disease patients, who were planned to undergo elective percutaneous coronary intervention in a single center, were randomized 1:1:1 to either a standard clopidogrel regimen or 1 of 2 regimens of ticagrelor, either 90 mg (T90) or 60 mg twice daily (T60), both with a 180 mg loading dose. Cellular adenosine uptake was assessed, at the time of the procedure and pre- and postdose at 1 month, by adding adenosine 1 µmol/L to aliquots of anticoagulated whole blood and mixing with a stop solution at 0, 15, 30, and 60 seconds, then measuring residual plasma adenosine concentration by high-performance liquid chromatography. Systemic plasma adenosine concentration and platelet reactivity were assessed at the same timepoints. High-sensitivity troponin T was measured pre- and 18 to 24 hours postpercutaneous coronary intervention. RESULTS One hundred seventy-four patients underwent an invasive procedure, of whom 162 received percutaneous coronary intervention (mean age 65 years, 18% female, 21% with diabetes mellitus). No effect on in vitro adenosine uptake was seen postdose at 1 month for either ticagrelor dose compared with clopidogrel (residual adenosine at 15 seconds, mean±SD: clopidogrel 0.274±0.101 µmol/L; T90 0.278±0.134 µmol/L; T60 0.288±0.149 µmol/L; P=0.37). Similarly, no effect of ticagrelor on in vitro adenosine uptake was seen at other timepoints, nor was plasma adenosine concentration affected (all P>0.1). Both maintenance doses of ticagrelor achieved more potent and consistent platelet inhibition than clopidogrel (VerifyNow P2Y12 reaction units, 1 month, mean±SD: predose, T60: 62±47, T90: 40±38, clopidogrel 181±44; postdose, T60: 34±30, T90: 24±21, clopidogrel 159±57; all P<0.0001 for ticagrelor versus clopidogrel). High platelet reactivity was markedly less with both T60 and T90 compared with clopidogrel (VerifyNow P2Y12 reaction units>208, 1 month postdose: 0%, 0%, and 21%, respectively). Median (interquartile range) high-sensitivity troponin T increased 16.9 (6.5-46.9) ng/L for clopidogrel, 22.4 (5.5-53.8) ng/L for T60, and 17.7 (8.1-43.5) ng/L for T90 (P=0.95). There was a trend toward less dyspnea with T60 versus T90 (7.1% versus 19.0%; P=0.09). CONCLUSIONS Maintenance therapy with T60 or T90 had no detectable effect on cellular adenosine uptake at 1 month, nor was there any effect on systemic plasma adenosine levels. Both regimens of ticagrelor achieved greater and more consistent platelet inhibition than clopidogrel but did not appear to affect troponin release after percutaneous coronary intervention. CLINICAL TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov. Unique identifier: NCT02327624.
Collapse
Affiliation(s)
- Rachel C. Orme
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - William A.E. Parker
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Mark R. Thomas
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
- University of Birmingham, United Kingdom (M.R.T.)
| | - Heather M. Judge
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
| | - Kathleen Baster
- Statistical Services Unit, (K.B.), University of Sheffield, United Kingdom
| | - Wael Sumaya
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Kenneth P. Morgan
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Hannah C. McMellon
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - James D. Richardson
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Ever D. Grech
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Nigel M. Wheeldon
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Ian R. Hall
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Javaid Iqbal
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - David Barmby
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Julian P. Gunn
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease (R.C.O., W.A.E.P., M.R.T., H.M.J., W.S., H.C.M., J.I., J.P.G., R.F.S.), University of Sheffield, United Kingdom
- Sheffield Teaching Hospitals National Health Service Foundation Trust, United Kingdom (R.C.O., W.A.E.P., M.R.T., W.S., K.P.M., H.C.M., J.D.R., E.D.G., N.M.W., I.R.H., J.I., D.B., J.P.G., R.F.S)
| |
Collapse
|