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Al-Maashari S, Al-Malki Y, Al Lawati H, Al-Riyami A, Nadar SK. Angiographic Predictors of Viability During Intervention for a ST Elevation Myocardial Infarction. Sultan Qaboos Univ Med J 2023; 23:38-43. [PMID: 38161757 PMCID: PMC10754314 DOI: 10.18295/squmj.12.2023.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/09/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives This study aimed to identify angiographic features that would predict myocardial viability after coronary intervention for ST elevation myocardial infarction (STEMI). Methods This retrospective study included patients who attended Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 with a STEMI. Results A total of 72 patients (61 male; mean age = 54.9 ± 12.7 years) were included in the study; 11 patients had evidence of non-viability on echocardiography. There were 13 patients with viable myocardium and 3 with non-viable myocardium who had a myocardial blush grade (MBG) of 2 or lower. Similarly, 10 patients with viability and 1 with non-viable myocardium had thrombolysis in myocardial infarction (TIMI) flow of 2 or lower in the infarct related artery (IRA). However, none of these were statistically significant. The TIMI flow in the IRA at the end of the procedure correlated with the MBG. Conclusion There were no clear angiographic features during primary angioplasty that could predict myocardial viability.
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Affiliation(s)
| | | | - Hatim Al Lawati
- Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Adil Al-Riyami
- Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Sunil K Nadar
- Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
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Ko D, Pande A, Lin KJ, Cervone A, Bessette LG, Lee SB, Cheng S, Glynn RJ, Kim DH. Utilization of P2Y 12 Inhibitors in Older Adults With ST-Elevation Myocardial Infarction and Frailty. Am J Cardiol 2023; 207:245-252. [PMID: 37757521 PMCID: PMC10840744 DOI: 10.1016/j.amjcard.2023.08.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 09/29/2023]
Abstract
Choosing optimal P2Y12 inhibitor in frail older adults is challenging because they are at increased risk of both ischemic and bleeding events. We conducted a retrospective cohort study of Medicare Advantage Plan beneficiaries who were prescribed clopidogrel, prasugrel, or ticagrelor after percutaneous coronary intervention-treated ST-elevation myocardial infarction from January 1, 2010 to December 31, 2020. Frailty was defined using claims-based frailty index ≥0.25. We conducted multivariable logistic regression to identify factors associated with using potent P2Y12 inhibitors and multivariable-adjusted competing risk analyses to compare the rate of discontinuation of potent P2Y12 inhibitors in frail versus non-frail patients. There were 11,239 patients (mean age 74 years, 39% women). The prevalence of cardiovascular and geriatric co-morbidities was as follows: 32% chronic kidney disease, 28% heart failure, 10% previous myocardial infarction, 6% dementia, 20% anemia, and 12% frailty. The proportion of patients receiving clopidogrel decreased from 78.3% in 2010 to 2013 to 42.1% in 2018 to 2020, with a concurrent increase in those receiving potent P2Y12 inhibitors (mostly ticagrelor) from 21.7% to 57.9%. Frailty was independently associated with reduced odds of initiation (odds ratio 0.78, 95% confidence interval 0.67 to 0.90) but not with discontinuation of potent P2Y12 inhibitors (subdistribution hazard ratio 1.09, 95% confidence interval 0.98 to 1.22). In conclusion, frail older adults are less likely to receive potent P2Y12 inhibitors after percutaneous coronary intervention-treated ST-elevation myocardial infarction, but they are as likely as non-frail patients to continue with the prescribed P2Y12 inhibitor.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts; Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Ashvin Pande
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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Virk HUH, Escobar J, Rodriguez M, Bates ER, Khalid U, Jneid H, Birnbaum Y, Levine GN, Smith SC, Krittanawong C. Dual Antiplatelet Therapy: A Concise Review for Clinicians. Life (Basel) 2023; 13:1580. [PMID: 37511955 PMCID: PMC10381391 DOI: 10.3390/life13071580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) combines two antiplatelet agents to decrease the risk of thrombotic complications associated with atherosclerotic cardiovascular diseases. Emerging data about the duration of DAPT is being published continuously. New approaches are trying to balance the time, benefits, and risks for patients taking DAPT for established cardiovascular diseases. Short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT for patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting. Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk. Extended DAPT does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death. Ticagrelor and aspirin reduce cardiovascular events in stable coronary artery disease with diabetes but carry a higher bleeding risk. Antiplatelet therapy duration in atrial fibrillation patients after percutaneous coronary intervention depends on individual characteristics and bleeding risk. Antiplatelet therapy is crucial for post-coronary artery bypass graft and transcatheter aortic valve implantation; Aspirin (ASA) monotherapy is preferred. Antiplatelet therapy duration in peripheral artery disease depends on the scenario. Adding vorapaxar and cilostazol may benefit secondary prevention and claudication, respectively. Carotid artery disease patients with transient ischemic attack or stroke benefit from antiplatelet therapy and combining ASA and clopidogrel is more effective than ASA alone. The optimal duration of DAPT after carotid artery stenting is uncertain. Resistance to ASA and clopidogrel poses an incremental risk of deleterious cardiovascular events and stroke. The selection and duration of antiplatelet therapy in patients with cardiovascular disease requires careful consideration of both efficacy and safety outcomes. The use of combination therapies may provide added benefits but should be weighed against the risk of bleeding. Further research and clinical trials are needed to optimize antiplatelet treatment in different patient populations and clinical scenarios.
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Affiliation(s)
- Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH 44101, USA
| | - Johao Escobar
- International Transitional Medical Graduate, American College of Physician, Philadelphia, PA 19106, USA
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital, Washington University, St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Umair Khalid
- Michael E. DeBakey VA Medical Center, Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77555, USA
| | - Yochai Birnbaum
- Michael E. DeBakey VA Medical Center, Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Glenn N Levine
- Michael E. DeBakey VA Medical Center, Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Sidney C Smith
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chayakrit Krittanawong
- Cardiology Division, NYU School of Medicine, NYU Langone Health, New York, NY 10016, USA
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Chen W, Tan X, Du X, Li Q, Yuan M, Ni H, Wang Y, Du J. Prediction models for major adverse cardiovascular events following ST-segment elevation myocardial infarction and subgroup-specific performance. Front Cardiovasc Med 2023; 10:1181424. [PMID: 37180806 PMCID: PMC10167292 DOI: 10.3389/fcvm.2023.1181424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Background ST-segment elevation myocardial infarction (STEMI) patients are at a high residual risk of major adverse cardiovascular events (MACEs) after revascularization. Risk factors modify prognostic risk in distinct ways in different STEMI subpopulations. We developed a MACEs prediction model in patients with STEMI and examined its performance across subgroups. Methods Machine-learning models based on 63 clinical features were trained in patients with STEMI who underwent PCI. The best-performing model (the iPROMPT score) was further validated in an external cohort. Its predictive value and variable contribution were studied in the entire population and subgroups. Results Over 2.56 and 2.84 years, 5.0% and 8.33% of patients experienced MACEs in the derivation and external validation cohorts, respectively. The iPROMPT score predictors were ST-segment deviation, brain natriuretic peptide (BNP), low-density lipoprotein cholesterol (LDL-C), estimated glomerular filtration rate (eGFR), age, hemoglobin, and white blood cell (WBC) count. The iPROMPT score improved the predictive value of the existing risk score, with an increase in the area under the curve to 0.837 [95% confidence interval (CI): 0.784-0.889] in the derivation cohort and 0.730 (95% CI: 0.293-1.162) in the external validation cohort. Comparable performance was observed between subgroups. The ST-segment deviation was the most important predictor, followed by LDL-C in hypertensive patients, BNP in males, WBC count in females with diabetes mellitus, and eGFR in patients without diabetes mellitus. Hemoglobin was the top predictor in non-hypertensive patients. Conclusion The iPROMPT score predicts long-term MACEs following STEMI and provides insights into the pathophysiological mechanisms for subgroup differences.
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Affiliation(s)
- Weiyao Chen
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
| | - Xin Tan
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
| | - Xiaoyu Du
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
- Center for Cardiovascular Medicine, The First Hospital of Jilin University, Changchun, China
| | - Qin Li
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
| | - Meng Yuan
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
| | - Hui Ni
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
| | - Yuan Wang
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
| | - Jie Du
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Collaborative Innovation Centre for Cardiovascular Disorders, Beijing, China
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Wang Y, Cavallari LH, Brown JD, Thomas CD, Winterstein AG. Assessing the Clinical Treatment Dynamics of Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention in the US. JAMA Netw Open 2023; 6:e238585. [PMID: 37067798 PMCID: PMC10111179 DOI: 10.1001/jamanetworkopen.2023.8585] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Importance A platelet ADP P2Y12 receptor (P2Y12) inhibitor plus aspirin is standard therapy for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Compared with clopidogrel, prasugrel and ticagrelor are associated with superior antiatherothrombotic effects but increased bleeding risk; with recent guideline updates, it is important to describe current treatment patterns and the role of bleeding risk in treatment choice. Objective To describe secular trends and determinants of initial P2Y12 inhibitor choice and switching, including deescalation (switch from prasugrel or ticagrelor to clopidogrel). Design, Setting, and Participants This retrospective cohort study used MarketScan Commercial Claims Data from 2010 to 2019 for patients aged 18 years or older who underwent PCI for ACS, had no P2Y12 inhibitor use in the past year, and filled a P2Y12 inhibitor prescription within 30 days after PCI hospitalization discharge. Data were analyzed from February to May 2022. Exposures Clopidogrel, prasugrel, and ticagrelor, with determinants including bleeding risk measured using Academic Research Consortium for High Bleeding Risk criteria, sociodemographic characteristics, P2Y12 inhibitor copays, and bleeding events during follow-up. Main Outcomes and Measures The prevalence of each P2Y12 inhibitor among patients who initiated the drugs and the prevalence of switching within 12 months after PCI were evaluated. The association between baseline bleeding risk and bleeding manifestations during follow-up and initial treatment and deescalation were calculated using multivariable logistic and Cox proportional hazards regression models. Results Between 2010 and 2019, 62 423 patients were identified who initiated P2Y12 inhibitors (females, 22.4%; males, 77.6%; mean [SD] age, 54.32 [7.13] years). The prevalence of clopidogrel as initial therapy decreased from 77.5% in 2010 to 29.6% in 2019, while initial use of prasugrel or ticagrelor increased from 22.5% to 60.4%. Within 1 year after PCI, 11.0% of patients switched therapy, mostly for deescalation. Deescalation prevalence increased from 1.8% in 2010 to 12.6% in 2018. Between 2016 and 2018, 8588 of 22 886 (37.5%) patients had major baseline bleeding risk, which decreased the selection of prasugrel or ticagrelor as initial therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.84). Among 11 285 patients who initiated prasugrel or ticagrelor, major bleeding risk at baseline (adjusted hazard ratio, 1.11; 95% CI, 1.00-1.23) and the occurrence of bleeding during follow-up (adjusted hazard ratio, 4.42; 95% CI, 3.62-5.93) were associated with deescalation. Conclusions and Relevance A strong shift in preference for prasugrel and ticagrelor as initial therapy following PCI for ACS was observed. Deescalation increased over the study period. Major bleeding risk at baseline was moderately associated with initial treatment choice but had a limited association with deescalation. The increasing use of more potent P2Y12 inhibitors emphasizes opportunities to enhance preemptive patient-centered treatment strategies to maintain optimal antiplatelet activity while reducing bleeding risk during the subacute period following PCI for ACS.
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Affiliation(s)
- Yehua Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, University of Florida, Gainesville
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Masuda S, Muramatsu T, Ishibashi Y, Kozuma K, Tanabe K, Nakatani S, Kogame N, Nakamura M, Asano T, Okamura T, Miyazaki Y, Tateishi H, Ozaki Y, Nakazawa G, Morino Y, Katagiri Y, Garg S, Hara H, Ono M, Kawashima H, Lemos PA, Serruys PW, Onuma Y. Reduced-dose prasugrel monotherapy without aspirin after PCI with the SYNERGY stent in East Asian patients presenting with chronic coronary syndromes or non-ST-elevation acute coronary syndromes: rationale and design of the ASET Japan pilot study. ASIAINTERVENTION 2023; 9:39-48. [PMID: 36936091 PMCID: PMC10018289 DOI: 10.4244/aij-d-22-00033] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 09/01/2022] [Indexed: 06/18/2023]
Abstract
The Acetyl Salicylic Elimination Trial (ASET) Japan pilot study is a multicentre, single-arm, open-label, proof-of-concept study with a stopping rule based on the occurrence of definite stent thrombosis. This study aims to demonstrate the feasibility and safety of low-dose prasugrel monotherapy following percutaneous coronary intervention (PCI) in Japanese patients presenting with chronic coronary syndromes (CCS) or non-ST-elevation acute coronary syndromes (NSTE-ACS). Four hundred patients with a SYNTAX score <23 requiring PCI due to CCS or NSTE-ACS will be screened and considered eligible for the study. The enrolment is planned in two phases: 1) 200 patients presenting with CCS, followed by 2) 200 patients presenting with NSTE-ACS. After optimal PCI with implantation of a SYNERGY (Boston Scientific) stent, patients will be enrolled and loaded with prasugrel 20 mg, followed by a maintenance dose of prasugrel 3.75 mg once daily without aspirin continued for 3 months in Phase 1 (CCS patients), and for 12 months in Phase 2 (NSTE-ACS patients). After these follow-up periods, prasugrel will be replaced by standard antiplatelet therapy according to local practice. The primary endpoint is a composite of cardiac death, target vessel myocardial infarction, or definite stent thrombosis after the index procedure. The primary bleeding endpoint is any Bleeding Academic Research Consortium type 3 or 5 bleeding occurring within 3 months of the index PCI for CCS patients, or 12 months for NSTE-ACS patients. The ASET Japan study is designed to demonstrate the feasibility and safety of reduced-dose prasugrel monotherapy after PCI in East Asian patients with acute and chronic coronary syndromes.
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Affiliation(s)
- Shinichiro Masuda
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Yuki Ishibashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Shimpei Nakatani
- Department of Cardiology, JCHO Hoshigaoka Medical Center, Osaka, Japan
| | - Norihiro Kogame
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Taku Asano
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Takayuki Okamura
- Division of Cardiology, Department of Clinical Science and Medicine, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yosuke Miyazaki
- Division of Cardiology, Department of Clinical Science and Medicine, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Hiroki Tateishi
- Division of Cardiology, Department of Clinical Science and Medicine, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
- Department of Cardiology, Shibata Hospital, Aichi, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Okazaki Medical Center, Aichi, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Iwate, Japan
| | - Yuki Katagiri
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Hokkaido, Japan
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, UK
| | - Hironori Hara
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - Pedro A Lemos
- Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
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7
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Muacevic A, Adler JR, Contreras R, Jacobson A, Jarrett R. An Uncommon Case of Acute Coronary Stent Thrombosis. Cureus 2023; 15:e33834. [PMID: 36655155 PMCID: PMC9842189 DOI: 10.7759/cureus.33834] [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] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
Coronary stent thrombosis is an uncommon complication of percutaneous coronary intervention, which can result in myocardial infarction and often death. We present a case of acute stent thrombosis in a patient with newly diagnosed triple vessel coronary artery disease occurring within less than an hour of stent placement along with a review of the literature.
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Konijnenberg LSF, Zugwitz D, Everaars H, Hoeven NWVD, Demirkiran A, Rodwell L, van Leeuwen MA, van Rossum AC, El Messaoudi S, Riksen NP, Royen NV, Nijveldt R. Effect of ticagrelor and prasugrel on remote myocardial inflammation in patients with acute myocardial infarction with ST-elevation: a CMR T1 and T2 mapping study. Int J Cardiovasc Imaging 2022; 39:767-779. [PMID: 36494503 DOI: 10.1007/s10554-022-02765-y] [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: 09/26/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Acute myocardial ischaemia triggers a non-specific inflammatory response of remote myocardium through the increase of plasma concentrations of acute-phase proteins, which causes myocardial oedema. As ticagrelor has been shown to significantly decrease circulating levels of several pro-inflammatory cytokines in patients after acute myocardial infarction with ST-elevation (STEMI), we sought to investigate a potential suppressive effect of ticagrelor over prasugrel on cardiac magnetic resonance (CMR) T1 and T2 values in remote myocardium. METHODS Ninety STEMI patients were prospectively included and randomised to receive either ticagrelor or prasugrel maintenance treatment after successful primary percutaneous coronary intervention. Patients underwent CMR after 2-7 days. The protocol included long and short axis cine imaging, T1 mapping, T2 mapping and late gadolinium enhancement imaging. RESULTS After excluding 30 patients due to either missing images or insufficient quality of the T1 or T2 maps, 60 patients were included in our analysis. Of those, 29 patients were randomised to the ticagrelor group and 31 patients to the prasugrel group. In the remote myocardium, T1 values did not differ between groups (931.3 [919.4-950.4] ms for ticagrelor vs. 932.6 [915.5-949.2] ms for prasugrel (p = 0.94)), nor did the T2 values (53.8 ± 4.6 ms for ticagrelor vs. 53.7 ± 4.7 ms for prasugrel (p = 0.86)). Also, in the infarcted myocardium, T1 and T2 values did not differ between groups. CONCLUSION In revascularised STEMI patients, ticagrelor maintenance therapy did not show superiority over prasugrel in preventing early remote myocardial inflammation as assessed by CMR T1 and T2 mapping.
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Li Y, Liang Z, Qin L, Wang M, Wang X, Zhang H, Liu Y, Li Y, Jia Z, Liu L, Zhang H, Luo J, Dong S, Guo J, Zhu H, Li S, Zheng H, Liu L, Wu Y, Zhong Y, Qiu M, Han Y, Stone GW. Bivalirudin plus a high-dose infusion versus heparin monotherapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a randomised trial. Lancet 2022; 400:1847-1857. [PMID: 36351459 DOI: 10.1016/s0140-6736(22)01999-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Previous randomised trials of bivalirudin versus heparin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have reported conflicting results, in part because of treatment with different pharmacological regimens. We designed a large-scale trial examining bivalirudin with a post-PCI high-dose infusion compared with heparin alone, the regimens that previous studies have shown to have the best balance of safety and efficacy. METHODS BRIGHT-4 was an investigator-initiated, open-label, randomised controlled trial conducted at 87 clinical centres in 63 cities in China. Patients with STEMI undergoing primary PCI with radial artery access within 48 h of symptom onset who had not received previous fibrinolytic therapy, anticoagulants, or glycoprotein IIb/IIIa inhibitors were randomly assigned (1:1) to receive bivalirudin with a post-PCI high-dose infusion for 2-4 h or unfractionated heparin monotherapy. There was no masking. Glycoprotein IIb/IIIa inhibitor use was reserved for procedural thrombotic complications in both groups. The primary endpoint was a composite of all-cause mortality or Bleeding Academic Research Consortium (BARC) types 3-5 bleeding at 30 days. This trial is registered with ClinicalTrials.gov (NCT03822975), and is ongoing. FINDINGS Between Feb 14, 2019, and April 7, 2022, a total of 6016 patients with STEMI undergoing primary PCI were randomly assigned to receive either bivalirudin plus a high-dose infusion after PCI (n=3009) or unfractionated heparin monotherapy (n=3007). Radial artery access was used in 5593 (93·1%) of 6008 patients. Compared with heparin monotherapy, bivalirudin reduced the 30-day rate of the primary endpoint (132 events [4·39%] in the heparin group vs 92 events [3·06%] in the bivalirudin group; difference, 1·33%, 95% CI 0·38-2·29%; hazard ratio [HR] 0·69, 95% CI 0·53-0·91; p=0·0070). All-cause mortality within 30 days occurred in 118 (3·92%) heparin-assigned patients and in 89 (2·96%) bivalirudin-assigned patients (HR 0·75; 95% CI 0·57-0·99; p=0·0420), and BARC types 3-5 bleeding occurred in 24 (0·80%) heparin-assigned patients and five (0·17%) bivalirudin-assigned patients (HR 0·21; 95% CI 0·08-0·54; p=0·0014). There were no significant differences in the 30-day rates of reinfarction, stroke, or ischaemia-driven target vessel revascularisation between the groups. Within 30 days, stent thrombosis occurred in 11 (0·37%) of bivalirudin-assigned patients and 33 (1·10%) of heparin-assigned patients (p=0·0015). INTERPRETATION In patients with STEMI undergoing primary PCI predominantly with radial artery access, anticoagulation with bivalirudin plus a post-PCI high-dose infusion for 2-4 h significantly reduced the 30-day composite rate of all-cause mortality or BARC types 3-5 major bleeding compared with heparin monotherapy. FUNDING Chinese Society of Cardiology Foundation (CSCF2019A01), and a research grant from Jiangsu Hengrui Pharmaceuticals.
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Affiliation(s)
- Yi Li
- General Hospital of Northern Theater Command, Shenyang, China
| | - Zhenyang Liang
- General Hospital of Northern Theater Command, Shenyang, China
| | - Lei Qin
- Kaifeng Central Hospital, Kaifeng, China
| | - Mian Wang
- West China Hospital of Sichuan University, Chengdu, China
| | | | | | - Yin Liu
- Tianjin Chest Hospital, Tianjin, China
| | - Yan Li
- Tangdu Hospital of Airforce Medical University, Xi'an, China
| | - Zhisheng Jia
- The Fifth People's Hospital of Jinan, Jinan, China
| | - Limin Liu
- The Second Hospital of Shenyang Medical College, Shenyang, China
| | - Hongyan Zhang
- Affiliated Hospital of Qilu Medical University, The People's Hospital of Xintai City, Xintai, China
| | - Jun Luo
- Ganzhou People's Hospital, Ganzhou, China
| | | | - Jincheng Guo
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | | | - Shengli Li
- Shangqiu First People's Hospital, Shangqiu, China
| | | | - Lijun Liu
- The First Affiliated Hospital of Anhui University of Science and Technology, Huainan, China
| | - Yanqing Wu
- The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yiming Zhong
- The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Miaohan Qiu
- General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China.
| | - Gregg W Stone
- Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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10
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Godtfredsen SJ, Kragholm KH, Leutscher P, Jørgensen SH, Christensen MK, Butt JH, Gislason G, Køber L, Fosbøl EL, Sessa M, Bhatt DL, Torp-Pedersen C, Pareek M. Effectiveness and safety of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a nationwide registry-based study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:697-705. [PMID: 35950769 DOI: 10.1093/ehjacc/zuac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/10/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
AIMS To compare the effectiveness and safety of clopidogrel, ticagrelor, and prasugrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS Nationwide, registry-based study of STEMI patients treated with primary PCI (2011-17) and subsequently with aspirin and a P2Y12 inhibitor. The effectiveness outcome was major adverse cardiovascular events (MACE) defined as a composite of recurrent myocardial infarction, repeat revascularization, stroke, or cardiovascular death at 12 months. The safety outcome was bleeding requiring hospitalization at 12 months. Multivariable logistic regression with average treatment effect modeling was used to calculate absolute and relative risks for outcomes standardized to the distributions of demographic characteristics of all included subjects. We included 10 832 patients; 1 697 were treated with clopidogrel, 7 508 with ticagrelor, and 1,627 with prasugrel. Median ages were 66, 63, and 59 years (P < 0.001). Standardized relative risks of MACE were 0.75 for ticagrelor vs. clopidogrel (95% confidence interval [CI], 0.64-0.83), 0.84 for prasugrel vs. clopidogrel (95% CI, 0.73-0.94), and 1.12 for prasugrel vs. ticagrelor (95% CI, 1.00-1.24). Standardized relative risks of bleeding were 0.77 for ticagrelor vs. clopidogrel (95% CI, 0.59-0.93), 0.89 for prasugrel vs. clopidogrel (95% CI, 0.64-1.15), and 1.17 for prasugrel vs. ticagrelor (95% CI, 0.89-1.45). CONCLUSION Ticagrelor and prasugrel were associated with lower risks of MACE after STEMI than clopidogrel, and ticagrelor was associated with a marginal reduction compared with prasugrel. The risk of bleeding was lower with ticagrelor compared with clopidogrel, but did not significantly differ between ticagrelor and prasugrel.
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Affiliation(s)
- Sissel J Godtfredsen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| | - Peter Leutscher
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Steen Hylgaard Jørgensen
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Martin Kirk Christensen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Jagtvej 160 Building 22, 2100 Copenhagen, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
| | - Christian Torp-Pedersen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
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11
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Ideal P2Y12 Inhibitor in Acute Coronary Syndrome: A Review and Current Status. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19158977. [PMID: 35897347 PMCID: PMC9331944 DOI: 10.3390/ijerph19158977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
Dual antiplatelet therapy (DAPT) has remained the cornerstone for management of acute coronary syndrome (ACS) over the years. Clopidogrel has been the quintessential P2Y12 receptor (platelet receptor for Adenosine 5′ diphosphate) inhibitor for the past two decades. With the demonstration of unequivocal superior efficacy of prasugrel/ticagrelor over clopidogrel, guidelines now recommend these agents in priority over clopidogrel in current management of ACS. Cangrelor has revived the interest in injectable antiplatelet therapy too. Albeit the increased efficacy of these newer agents comes at the cost of increased bleeding and this becomes more of a concern when combined with aspirin. Which P2Y12i is superior over another has been intensely debated over last few years after the ISAR-REACT 5 study with inconclusive data. Three novel antiplatelet agents are already in the pipeline for ACS with all of them succeeding in phase II studies. The search for an ideal antiplatelet remains a need of the hour for optimal reduction of ischemic events in ACS.
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12
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Kumar K, Golwala H. Antiplatelet Agents in Acute ST Elevation Myocardial Infarction. Am J Med 2022; 135:697-708. [PMID: 35202571 DOI: 10.1016/j.amjmed.2022.01.042] [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] [Received: 12/21/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
Abstract
Platelet aggregation and thrombus formation represent the basic mechanism for clinical, electrocardiographic, and biomarker changes consistent with acute coronary syndrome. Various oral and intravenous formulations of platelet function inhibitors have been developed to help decrease platelet aggregation due to acute atherosclerotic plaque rupture. In this article, we review the various mechanisms, pharmacokinetics/pharmacodynamics, and the key clinical trials related to the platelet inhibitors that form the basis for current recommendations of their use in the ST elevation myocardial infarction guidelines by the American College of Cardiology/American Heart Association.
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Affiliation(s)
- Kris Kumar
- Oregon Health and Science University, Portland, Ore
| | - Harsh Golwala
- Oregon Health and Science University, Portland, Ore.
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13
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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14
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Fabris E, Korjian S, Coller BS, Ten Berg JM, Granger CB, Gibson CM, van 't Hof AWJ. Pre-Hospital Antiplatelet Therapy for STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: What We Know and What Lies Ahead. Thromb Haemost 2021; 121:1562-1573. [PMID: 33677829 PMCID: PMC8604087 DOI: 10.1055/a-1414-5009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Early recanalization of the infarct-related artery to achieve myocardial reperfusion is the primary therapeutic goal in patients with ST-elevation myocardial infarction (STEMI). To decrease the duration of ischaemia, continuous efforts have been made to improve pre-hospital treatment and to target the early period after symptom onset. In this period the platelet content of the fresh coronary thrombus is maximal and the thrombi are dynamic, and thus more susceptible to powerful antiplatelet agents. There have been substantial advances in antiplatelet therapy in the last three decades with several classes of oral and intravenous antiplatelet agents with different therapeutic targets, pharmacokinetics, and pharmacodynamic properties. New parenteral drugs achieve immediate inhibition of platelet aggregation, and fast and easy methods of administration may create the opportunity to bridge the initial gap in platelet inhibition observed with oral P2Y12 inhibitors. Moreover, potential future management of STEMI could directly involve patients in the process of care with self-administered antiplatelet agents designed to achieve rapid reperfusion. However, the potential anti-ischaemic benefits of potent antiplatelet agents will need to be balanced against their risk of increased bleeding. This study presents a comprehensive and updated review of pre-hospital antiplatelet therapy among STEMI patients undergoing primary percutaneous intervention and explores new therapies under development.
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Affiliation(s)
- Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Serge Korjian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, United States
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christopher B Granger
- Duke Clinical Research Institute and the Division of Cardiology, Duke University Medical Center, Durham, North Carolina, United States
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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15
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Park S, Kim YG, Ann SH, Park HW, Suh J, Roh JH, Cho YR, Han S, Park GM. Ticagrelor versus prasugrel in patients with acute myocardial infarction. Int J Cardiol 2021; 344:25-30. [PMID: 34619265 DOI: 10.1016/j.ijcard.2021.09.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/18/2021] [Accepted: 09/30/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ticagrelor and prasugrel are the mainstay of antithrombotic therapy for patients with acute myocardial infarction (MI). However, direct comparative data on clinical outcomes of potent P2Y12 inhibitors are limited, especially in East Asian populations. We aimed to evaluate the effect of ticagrelor versus prasugrel on clinical outcomes in patients with acute MI. METHODS From the Korean nationwide National Health Insurance database, 10,797 patients with acute MI who received either ticagrelor or prasugrel in combination with aspirin after percutaneous coronary intervention (PCI) were enrolled. The primary outcome was net clinical benefit, defined as a composite of death, MI, stroke, or major bleeding. Secondary outcomes included the individual components of the primary outcome as effectiveness and safety measures. RESULTS Among 10,797 patients, 9591 (88.8%) received ticagrelor and 1206 (11.2%) received prasugrel. During a median follow-up of 1.8 years, the primary outcome occurred in 1051 (16.6%) and 131 (14.4%) patients in the ticagrelor and prasugrel groups, respectively. In the propensity score matched cohort (n = 5979), the risk for the primary outcome was similar between the two groups (hazard ratio [HR] 0.949 for prasugrel; 95% confidence interval [CI]: 0.780-1.154). The risks for the composite of death, MI, or stroke (HR 0.938; 95% CI: 0.752-1.169) and major bleeding (HR 1.022; 95% CI: 0.709-1.472) were also comparable. CONCLUSIONS In patients with acute MI undergoing PCI, ticagrelor and prasugrel appeared to have similar net clinical benefits. The risks for death, MI, or stroke and major bleeding were not significantly different between the two groups.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Yong-Giun Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Soe Hee Ann
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Hyun Woo Park
- Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon, Republic of Korea
| | - Jon Suh
- Department of Cardiology, Soon Chun Hyang University Hospital Bucheon, Bucheon, Republic of Korea
| | - Jae-Hyung Roh
- Department of Cardiology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Young-Rak Cho
- Department of Cardiology, Dong-A University Hospital, Busan, Republic of Korea
| | - Seungbong Han
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Republic of Korea.
| | - Gyung-Min Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
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16
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Eliaz R, Mengesha B, Ovdat T, Iakobishvili Z, Hasdai D, Kheifets M, Klempfner R, Beigel R, Kalmanovich E, Alcalai R, Levi A. Ticagrelor versus Prasugrel in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention - analysis from the Acute Coronary Syndrome Israeli Survey (ACSIS). Cardiology 2021; 147:113-120. [PMID: 34808635 DOI: 10.1159/000521042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to compare the outcomes of ACS (acute coronary syndrome) patients undergoing in-hospital PCI (percutaneous coronary intervention) treated with prasugrel versus ticagrelor. METHODS Among 7,233 patients enrolled to the ACSIS (Acute Coronary Syndrome Israeli Survey) between 2010 and 2018, we identified 1126 eligible patients treated with prasugrel and 817 with ticagrelor. Comparison between the groups was preformed separately in ST-elevation myocardial infarction (STEMI) patients, propensity score matched (PSM) STEMI patients, and non-ST-elevation ACS (NSTE-ACS) patients. RESULTS In-hospital complication rates, including rates of stent thrombosis, were not significantly different between groups. In PSM STEMI patients, 30-day re-hospitalization rate (p <0.05), 30-day MACE (the composite of death, MI, stroke and urgent revascularization; p=0.006), and 1-year mortality rates (p = 0.08) were higher in the ticagrelor group compared to the prasugrel group; In NSTE-ACS patients, outcomes were not associated with drug choice. In cox regression analysis applied on the entire cohort, prasugrel was associated with lower 1-year mortality in STEMI patient but not in NSTE-ACS patients (p for interaction 0.03). CONCLUSIONS Compared to ticagrelor, prasugrel was associated with superior clinical outcomes in STEMI patients, but not in NSTE-ACS patients.
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Affiliation(s)
- Ran Eliaz
- Department of Cardiology, Hadassah Medical Center, Israel and the Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Bethlehem Mengesha
- Shamir Medical Center, Be'er Ya'acov, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Ovdat
- Israel Center for Cardiovascular Research, Sheba Medical Center, Ramat-Gan, Israel
| | - Zaza Iakobishvili
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Kupat Holim Clalit, Tel Aviv District, Tel Aviv, Israel
| | - David Hasdai
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Mark Kheifets
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Robert Klempfner
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Israel Center for Cardiovascular Research, Sheba Medical Center, Ramat-Gan, Israel
- The Cardiovascular Division Sheba Medical Center, Department of Cardiology, Tel-Hashomer, Ramat-Gan, Israel
| | - Roy Beigel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Cardiovascular Division Sheba Medical Center, Department of Cardiology, Tel-Hashomer, Ramat-Gan, Israel
| | - Eran Kalmanovich
- Shamir Medical Center, Be'er Ya'acov, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronny Alcalai
- Department of Cardiology, Hadassah Medical Center, Israel and the Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Amos Levi
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
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17
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Wöhrle J, Seeger J, Lahu S, Mayer K, Bernlochner I, Gewalt S, Menichelli M, Witzenbichler B, Hochholzer W, Sibbing D, Cassese S, Angiolillo DJ, Hemetsberger R, Valina C, Kufner S, Xhepa E, Hapfelmeier A, Sager HB, Joner M, Richardt G, Laugwitz KL, Neumann FJ, Schunkert H, Schüpke S, Kastrati A, Ndrepepa G. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndrome in Relation to Estimated Glomerular Filtration Rate. JACC Cardiovasc Interv 2021; 14:1857-1866. [PMID: 34446390 DOI: 10.1016/j.jcin.2021.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to assess the safety and efficacy of ticagrelor versus prasugrel for patients with acute coronary syndrome (ACS) according to their estimated glomerular filtration rates (eGFRs). BACKGROUND The outcomes of ticagrelor versus prasugrel in patients with ACS according to eGFR have not been defined. METHODS Patients (n = 4,012) were categorized into 3 groups: low eGFR (<60 mL/min/1.73 m2), intermediate eGFR (≥60 and <90 mL/min/1.73 m2), and high eGFR (≥90 mL/min/1.73 m2). The primary endpoint was a composite of all-cause death, myocardial infarction, and stroke; the secondary safety endpoint was Bleeding Academic Research Consortium types 3 to 5 bleeding, both at 1 year. RESULTS Patients with low eGFRs had a higher risk for the primary endpoint compared with patients with intermediate eGFRs (adjusted HR: 1.89; 95% CI: 1.46-2.46]) and those with high eGFRs (adjusted HR: 2.33; 95% CI: 1.57-3.46). A risk excess for low eGFR was also observed for bleeding (adjusted HR: 1.55 [95% CI: 1.12-2.13] vs intermediate eGFR; adjusted HR: 1.59 [95% CI: 1.01-2.50] vs high eGFR). However, eGFR did not affect the relative efficacy and safety of ticagrelor versus prasugrel. In patients with low eGFR, the primary endpoint occurred in 20.5% with ticagrelor and in 14.7% with prasugrel (HR: 1.47; 95% CI: 1.04-2.08; P = 0.029); there was no significant difference in bleeding. CONCLUSIONS These results show that among patients with ACS, reduction of eGFR is associated with increased risk for ischemic and bleeding events but has no significant impact on the relative efficacy and safety of ticagrelor versus prasugrel. (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome [ISAR-REACT 5]; NCT01944800).
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Affiliation(s)
- Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany.
| | - Julia Seeger
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
| | - Shqipdona Lahu
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Katharina Mayer
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Senta Gewalt
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | | | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany; Klinik der Universität München, Ludwig-Maximilians-University, Cardiology, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
| | - Hendrik B Sager
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Franz Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
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18
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Liang B, Gu N. Evaluation of the Safety and Efficacy of Coronary Intravascular Lithotripsy for Treatment of Severely Calcified Coronary Stenoses: Evidence From the Serial Disrupt CAD Trials. Front Cardiovasc Med 2021; 8:724481. [PMID: 34490380 PMCID: PMC8416910 DOI: 10.3389/fcvm.2021.724481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/19/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Previous understanding holds that rotational atherectomy and modified balloons remain the default strategy for severely calcified coronary stenoses. In recent years, coronary intravascular lithotripsy (IVL) provides new ideas. This study was conducted to evaluate the safety and efficacy of IVL for the treatment of severely calcified coronary stenoses. Methods: The serial Disrupt CAD trials (Disrupt CAD I, Disrupt CAD II, Disrupt CAD III, and Disrupt CAD IV) were included in this study. The safety endpoint was freedom from major adverse cardiovascular events (MACE) in hospital, at 30 days, and at 6 months following the index procedure. The efficacy endpoints included procedural success and angiographic success. Optical coherence tomography (OCT) was used to evaluate the mechanism of action of IVL quantifying the coronary artery calcification (CAC) characteristics and calcium plaque fracture. Results: We enrolled a total of 628 patients with a mean age of 71.8 years, 77.1% males. In these patients, the left anterior descending artery and right coronary artery were the most vulnerable vessels. The diameter stenosis was 64.6 ± 11.6% and the lesion length was 24.2 ± 11.4 mm. IVL had a favorable efficacy (93.0% procedural success, 97.5% angiographic success, and 100.0% stent delivery). Among the 628 patients, 568, 568, and 60 reported MACE endpoints in hospital, at 30 days, and at 6 months, respectively. The results showed that 528, 514, and 55 patients were free from MACE in hospital, at 30 days, and at 6 months, respectively. OCT measurements demonstrated that calcium fracture was the underlying mechanism of action for coronary IVL. Conclusions: IVL is safe and efficient for severely calcified coronary stenoses, and, importantly, calcium fracture facilitated increased vessel compliance and favorable stent expansion.
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Affiliation(s)
- Bo Liang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Ning Gu
- Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
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19
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Gamal AS, Hara H, Tomaniak M, Lunardi M, Gao C, Ono M, Kawashima H, Jüni P, Vranckx P, Windecker S, Hamm C, Steg PG, Onuma Y, Serruys PW. 'Ticagrelor alone vs. dual antiplatelet therapy from 1 month after drug-eluting coronary stenting among patients with STEMI': a post hoc analysis of the randomized GLOBAL LEADERS trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:756-773. [PMID: 34212187 PMCID: PMC8483765 DOI: 10.1093/ehjacc/zuab033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/17/2021] [Accepted: 05/06/2021] [Indexed: 11/12/2022]
Abstract
AIM To evaluate the efficacy and safety of ticagrelor monotherapy beyond 1 month and up to 24 months vs. standard 12-month dual antiplatelet therapy (DAPT) with aspirin and ticagrelor followed by aspirin monotherapy among ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) in the GLOBAL LEADERS trial. METHODS AND RESULTS We performed a post hoc analysis of STEMI patients in the GLOBAL LEADERS trial comparing experimental ticagrelor monotherapy (1062 patients) with standard 12-month DAPT (1030 patients). We evaluated predefined primary and secondary endpoints in both treatment arms. Rates of net adverse clinical events (NACE), patient-oriented composite endpoints (POCE), and bleeding academic research consortium (BARC)-defined bleeding Type 3 or 5 were also evaluated. At 2 years, there were no significant differences in rates of primary endpoints in patients who had STEMI [0.89 (0.61-1.31)]. There were similar rates of NACE and POCE in both experimental and reference treatment groups at 2 years post-PCI [hazard ratio (HR) 0.96 (0.77-1.20) and 0.96 (0.77-1.21), respectively]. BARC 3 or 5 bleeding events were numerically less in experimental compared to reference treatment groups at 1 year [HR 0.55 (0.27-1.13)] and 2 years [0.61 (0.32-1.16)]. CONCLUSION Presentation with STEMI has not influenced the incidence of GLOBAL LEADERS defined primary endpoints. There were no significant differences in rates of NACE, POCE, and BARC bleeding between the two treatment groups up to 2 years of follow-up. Although these findings should be viewed as exploratory, they expand the evidence on potential safety of aspirin-free antiplatelet strategies after PCI in STEMI.
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Affiliation(s)
- Amr S Gamal
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, North Cumbria University Hospital NHS Trust, Newtown Road, Cumbria CA2 7HY, England, UK.,Department of Cardiology, Zagazig University, Zagazig, Sharkia, 44519, Egypt
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mariusz Tomaniak
- Department of Cardiology, Erasmus University MC, Dr. Molewaterplein 40 Street, 3015 GD Rotterdam, The Netherlands.,First Department of Cardiology, Medical University of Warsaw, Banacha 1a Street, 02-097 Warsaw, Poland
| | - Mattia Lunardi
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Division of Cardiology, University of Verona, Piazzale Stefani 1, Verona 37100, Italy
| | - Chao Gao
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street Toronto, Ontario M5B 1W8, Canada
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Christian Hamm
- Department of Cardiology, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Philippe Gabriel Steg
- Université de Paris, FACT, Assistance Publique-Hôpitaux de Paris Hôpital Bichat, AP-HP, 46 rue Henri Huchard, 75018 Paris, France
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Imperial College London, Exhibition Road, London SW7 2BX, UK
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20
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Coughlan JJ, Aytekin A, Ndrepepa G, Schüpke S, Bernlochner I, Mayer K, Neumann FJ, Menichelli M, Richardt G, Wöhrle J, Witzenbichler B, Gewalt S, Xhepa E, Kufner S, Sager HB, Joner M, Ibrahim T, Fusaro M, Laugwitz KL, Schunkert H, Kastrati A, Cassese S. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndrome Undergoing Complex Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2021; 14:e010565. [PMID: 34130477 DOI: 10.1161/circinterventions.121.010565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- J J Coughlan
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.).,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin (J.J.C.)
| | - Alp Aytekin
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Katharina Mayer
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
| | - Franz Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (F.J.N.)
| | | | | | - Jochen Wöhrle
- Department of Cardiology, Medical Campus Lake Constance, Friedrichshafen, Germany (J.W.)
| | | | - Senta Gewalt
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
| | - Erion Xhepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
| | - Hendrik B Sager
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Michael Joner
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Tareq Ibrahim
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (T.I., K.L.L.)
| | | | - Karl Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (T.I., K.L.L.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.).,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.S., I.B., H.B.S., M.J., K.L.L., H.S., A.K.)
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany (J.J.C., A.A., G.N., S.S., K.M., S.G., E.X., S.K., H.B.S., M.J., H.S., A.K., S.C.)
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21
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Ibanez B, Roque D, Price S. The year in cardiovascular medicine 2020: acute coronary syndromes and intensive cardiac care. Eur Heart J 2021; 42:884-895. [PMID: 33388774 DOI: 10.1093/eurheartj/ehaa1090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - David Roque
- Cardiology Department, Prof. Dr. Fernando Fonseca Hospital, Amadora, Portugal
| | - Susanna Price
- Department of Cardiology and Department of Adult Critical Care, Royal Brompton Hospital, London, UK
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22
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Hjortbak MV, Olesen KKW, Seefeldt JM, Lassen TR, Jensen RV, Perkins A, Dodd M, Clayton T, Yellon D, Hausenloy DJ, Bøtker HE. Translation of experimental cardioprotective capability of P2Y 12 inhibitors into clinical outcome in patients with ST-elevation myocardial infarction. Basic Res Cardiol 2021; 116:36. [PMID: 34037861 DOI: 10.1007/s00395-021-00870-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/13/2021] [Indexed: 11/25/2022]
Abstract
We studied the translational cardioprotective potential of P2Y12 inhibitors against acute myocardial ischemia/reperfusion injury (IRI) in an animal model of acute myocardial infarction and in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). P2Y12 inhibitors may have pleiotropic effects to induce cardioprotection against acute myocardial IRI beyond their inhibitory effects on platelet aggregation. We compared the cardioprotective effects of clopidogrel, prasugrel, and ticagrelor on infarct size in an in vivo rat model of acute myocardial IRI, and investigated the effects of the P2Y12 inhibitors on enzymatic infarct size (48-h area-under-the-curve (AUC) troponin T release) and clinical outcomes in a retrospective study of STEMI patients from the CONDI-2/ERIC-PPCI trial using propensity score analyses. Loading with ticagrelor in rats reduced infarct size after acute myocardial IRI compared to controls (37 ± 11% vs 52 ± 8%, p < 0.01), whereas clopidogrel and prasugrel did not (50 ± 11%, p > 0.99 and 49 ± 9%, p > 0.99, respectively). Correspondingly, troponin release was reduced in STEMI patients treated with ticagrelor compared to clopidogrel (adjusted 48-h AUC ratio: 0.67, 95% CI 0.47-0.94). Compared to clopidogrel, the composite endpoint of cardiac death or hospitalization for heart failure within 12 months was reduced in STEMI patients loaded with ticagrelor (HR 0.63; 95% CI 0.42-0.94) but not prasugrel (HR 0.84, 95% CI 0.43-1.63), prior to PPCI. Major adverse cardiovascular events did not differ between clopidogrel, ticagrelor, or prasugrel. The cardioprotective effects of ticagrelor in reducing infarct size may contribute to the clinical benefit observed in STEMI patients undergoing PPCI.
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Affiliation(s)
- Marie V Hjortbak
- Department of Clinical Medicine, Cardiology, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob M Seefeldt
- Department of Clinical Medicine, Cardiology, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Thomas R Lassen
- Department of Clinical Medicine, Cardiology, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Rebekka V Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Alexander Perkins
- London School of Hygiene and Tropical Medicine, Clinical Trials Unit, London, UK
| | - Matthew Dodd
- London School of Hygiene and Tropical Medicine, Clinical Trials Unit, London, UK
| | - Tim Clayton
- London School of Hygiene and Tropical Medicine, Clinical Trials Unit, London, UK
| | - Derek Yellon
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, UK.,Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore, Singapore.,National Heart Research Institute Singapore, National Hearts Centre, Singapore Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Singapore, Singapore
| | - Hans Erik Bøtker
- Department of Clinical Medicine, Cardiology, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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23
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Voll F, Kuna C, Ndrepepa G, Kastrati A, Cassese S. Antithrombotic treatment in primary percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:313-324. [PMID: 33705211 DOI: 10.1080/14779072.2021.1902807] [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: 10/21/2022]
Abstract
INTRODUCTION Despite a timely mechanical reperfusion with primary percutaneous coronary intervention (pPCI) patients presenting with ST-elevation myocardial infarction (STEMI) display an increased risk of adverse cardiovascular events. Several studies have demonstrated that guideline-directed antithrombotic therapy is effective to reduce this risk. However, there is still much to be accomplished to improve antithrombotic therapies in this clinical setting. AREAS COVERED This paper reviews current data on antithrombotic therapy in STEMI patients undergoing pPCI. EXPERT OPINION Antithrombotic therapy for STEMI patients undergoing pPCI should take into account the variability of thrombotic and bleeding risk in the short and long term. Patients with STEMI profit from the administration of early onset antiplatelet agents and anticoagulation to achieve sufficient and predictable antithrombotic effect at the time of pPCI. Thereafter, antithrombotic therapies should be tailored to individual risk of recurrence over the long term, to avoid excess bleeding, while ensuring adequate secondary ischemic prevention.
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Affiliation(s)
- Felix Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Constantin Kuna
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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24
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The 11-Year Prognostic Impact of Chronic Total Occlusion in the Noninfarct-Related Coronary Artery on Patients with Acute Myocardial Infarction. J Interv Cardiol 2021; 2021:6646804. [PMID: 33824627 PMCID: PMC7994075 DOI: 10.1155/2021/6646804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/13/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background The prognostic significance of CTO in the non-IRA in patients with AMI has been under dispute. Relevant long-term follow-up studies are lacking. Hypothesis. CTO in the non-IRA is an independent predictor of poor long-term prognosis in patients with AMI. Methods We prospectively enrolled 2336 patients with AMI who received emergent percutaneous coronary intervention successfully from January 2006 to May 2011. Our primary endpoints included death from cardiovascular causes, recurrent myocardial infarction, stroke, and target-vessel revascularization. We adopted Cox regression analysis adjusted for confounders to analyze the impact of CTO in the non-IRA on long-term mortalities. Results We identified 628 (27.6%) subjects with CTO in the non-IRA among 2282 AMI patients. After a mean follow-up duration of 134.3 months, we found the CTO group had significantly higher MACCE rate than the group without CTO (30.4% versus 24.3%, P=0.004). CTO in the non-IRA independently predicted 11-year MACCE in the male AMI subgroup (hazard ratio 1.28, 95% confidence interval 1.06 to 1.54, P=0.01) and in the male NSTEMI subgroup (hazard ratio 1.53, 95% confidence interval 1.09 to 2.15, P=0.02). In the CTO group, three-vessel disease independently predicted 11 year MACCE (hazard ratio 2.05, 95% confidence interval 1.29 to 3.28, P=0.002). Conclusions Our long-term observational study supported the association between CTO in the non-IRA and poorer prognosis in AMI patients undergoing primary PCI. We identified the group with the three-vessel disease as a high-risk subgroup in patients with CTO in the non-IRA.
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25
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Quality, efficacy, safety-it is not enough! Eur J Clin Pharmacol 2021; 77:1425-1426. [PMID: 33687517 DOI: 10.1007/s00228-021-03110-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
There is a need of comparative studies to understand the differences in term of efficacy and safety of drugs with different mechanisms of action but similar therapeutic indications. This requires changes in the European Legislation of criteria for drug approval.
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Werner N, Neumann FJ. Entwicklung kardiovaskuläre Medizin 2020. DER KARDIOLOGE 2021. [PMCID: PMC7944250 DOI: 10.1007/s12181-021-00461-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Auf dem Gebiet der ischämischen Herzerkrankungen war 2020 ein spannendes Jahr. Die COVID-19-Pandemie hat Diagnostik und Therapie der koronaren Herzkrankheit in vielen Bereichen stark beeinflusst. Daneben haben die Ergebnisse der ISCHEMIA-Studie zumindest in Teilen die bisherige Praxis in der Behandlung des stabilen, chronischen Koronarsyndroms (CCS) infrage gestellt. In dieser Studie konnte keine Prognoseverbesserung durch Myokardrevaskularisation bei Patienten mit stabiler Ischämie nachgewiesen werden, wohl aber eine Verbesserung von Lebensqualität und Angina-pectoris-Beschwerden. Darüber hinaus wurden neue europäische Leitlinien zum ACS (akutes Koronarsyndrom) ohne ST-Streckenhebung (NSTE-ACS) vorgestellt. Wichtige Publikationen aus dem Jahr 2020 führen die dort vorgestellten Konzepte weiter. So konnte der Nutzen der frühinvasiven Behandlung beim NSTE-ACS erstmals auch für die ≥ 80-Jährigen nachgewiesen werden. Neuere Analysen bestätigen ferner das Konzept der kompletten Revaskularisation bei ST-Hebungsinfarkt ohne Schock und Mehrgefäßerkrankung. Dieses Konzept wird nun auf das NSTE-ACS übertragen. In der antithrombozytären Therapie stellen aktuelle Studien die antithrombozytäre Vorbehandlung als Teil der frühinvasiven Strategie bei unbekanntem Koronarstatus infrage. Mehrere Studien zeigen den potenziellen Nutzen einer Deeskalation der antithrombozytären Therapie nach NSTE-ACS insbesondere bei älteren Patienten.
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Affiliation(s)
- Nikos Werner
- Herzzentrum Trier, Innere Medizin III – Kardiologie und Intensivmedizin, Krankenhaus der Barmherzigen Brüder Trier, Nordallee 1, 54292 Trier, Deutschland
| | - Franz-Josef Neumann
- Klinik für Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg ∙ Bad Krozingen, Südring 15, 79189 Bad Krozingen, Deutschland
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Hochholzer W, Valina CM. Antiplatelet therapy for STEMI: Hit it hard and early? Int J Cardiol 2021; 328:61-62. [PMID: 33412178 DOI: 10.1016/j.ijcard.2020.12.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 12/19/2020] [Accepted: 12/28/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Willibald Hochholzer
- University Heart Center Freiburg, Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany.
| | - Christian M Valina
- University Heart Center Freiburg, Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany
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