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Denardo SJ, Vlachos PP, Meyers BA, Babakhani-Galangashi R, Wang L, Gao Z, Tcheng JE. Translating proof-of-concept for platelet slip into improved antithrombotic therapeutic regimens. Platelets 2024; 35:2353582. [PMID: 38773939 DOI: 10.1080/09537104.2024.2353582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/03/2024] [Indexed: 05/24/2024]
Abstract
Platelets are central to thrombosis. Research at the intersection of biological and physical sciences provides proof-of-concept for shear rate-dependent platelet slip at vascular stenosis and near device surfaces. Platelet slip extends the observed biological "slip-bonds" to the boundary of functional gliding without contact. As a result, there is diminished engagement of the coagulation cascade by platelets at these surfaces. Comprehending platelet slip would more precisely direct antithrombotic regimens for different shear environments, including for percutaneous coronary intervention (PCI). In this brief report we promote translation of the proof-of-concept for platelet slip into improved antithrombotic regimens by: (1) reviewing new supporting basic biological science and clinical research for platelet slip; (2) hypothesizing the principal variables that affect platelet slip; (3) applying the consequent construct model in support of-and in some cases to challenge-relevant contemporary guidelines and their foundations (including for urgent, higher-risk PCI); and (4) suggesting future research pathways (both basic and clinical). Should future research demonstrate, explain and control platelet slip, then a paradigm shift for choosing and recommending antithrombotic regimens based on predicted shear rate should follow. Improved clinical outcomes with decreased complications accompanying this paradigm shift for higher-risk PCI would also result in substantive cost savings.
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Affiliation(s)
- Scott J Denardo
- Medicine/Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Pavlos P Vlachos
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, USA
| | - Brett A Meyers
- School of Mechanical Engineering, Purdue University, West Lafayette, IN, USA
| | | | - Lin Wang
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - Zejin Gao
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - James E Tcheng
- Medicine/Cardiology, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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2
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Larrubia Valle JI, Urbano-Carrillo CA, Costa F. Antithrombotic Therapy in Patients with Complex Percutaneous Coronary Intervention and Cardiogenic Shock. Interv Cardiol Clin 2024; 13:517-525. [PMID: 39245551 DOI: 10.1016/j.iccl.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Managing antithrombotic therapy in patients undergoing complex and high-risk in indicated patients, including those treated with complex percutaneous coronary intervention (PCI) or presenting with cardiogenic shock (CS), is challenging. This review highlights the critical role of antithrombotic therapy, during and after PCI, to optimize the efficacy while minimizing risks. Unfractionated heparin remains the mainstay anticoagulant for complex PCI and CS, with bivalirudin as a potential safer alternative. Cangrelor offers consistent antiplatelet effects, especially when timely absorption of oral agents is uncertain.
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Affiliation(s)
| | | | - Francesco Costa
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, Malaga 29010, Spain; Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, Messina 98122, Italy.
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3
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Liao J, Qiu M, Feng X, Chen K, Zhang D, Zou Y, Zheng X, Zhao G, Tian N, Zheng Z, Peng X, Yang Q, Liang Z, Li Y, Han Y, Stone GW. Bivalirudin versus heparin in patients with or without bail-out GPI use: a pre-specified subgroup analysis from the BRIGHT-4 trial. BMC Med 2024; 22:410. [PMID: 39334129 DOI: 10.1186/s12916-024-03579-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 08/22/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Conflicting results comparing bivalirudin versus heparin anticoagulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), in part due to the confounding effect of glycoprotein IIb/IIIa inhibitors (GPI). The aim of the study was to compare the safety and effectiveness of bivalirudin plus a post-PCI high-dose infusion vs heparin with or without bail-out GPI use. METHODS We conducted a pre-specified subgroup analysis from the BRIGHT-4 trial that randomized 6016 STEMI patients who underwent primary PCI to receive either bivalirudin plus a post-PCI high-dose infusion for 2-4 h or heparin monotherapy. GPI use was only reserved as bail-out therapy for procedural thrombotic complications. The primary outcome was a composite of all-cause death or Bleeding Academic Research Consortium (BARC) types 3-5 bleeding at 30 days. RESULTS A total of 5250 (87.4%) patients received treatment without GPI while 758 (12.6%) received bail-out GPI. Bail-out GPI use was associated with an increased risk of the primary outcome compared to non-GPI use (5.28% vs. 3.41%; adjusted hazard ratio (aHR), 1.62; 95% confidence interval (CI), 1.13-2.33; P = 0.009) and all-cause death (5.01% vs. 3.12%; aHR, 1.74; 95% CI, 1.20-2.52; P = 0.004) but not in the risk of BARC types 3-5 bleeding (0.53% vs. 0.48%; aHR, 0.90; 95% CI, 0.31-2.66; P = 0.85). Among patients without GPI use, bivalirudin was associated with lower rates of the primary outcome (2.63% vs. 4.21%; aHR, 0.55; 95% CI, 0.39-0.77; P = 0.0005), all-cause death (2.52% vs. 3.74%; aHR, 0.58; 95% CI, 0.41-0.83; P = 0.003), and BARC types 3-5 bleeding (0.15% vs. 0.81%; aHR, 0.19; 95% CI, 0.06-0.57; P = 0.003) compared with heparin. However, among patients requiring bail-out GPI, there were no significant differences observed in the rates of the primary outcome (5.76% vs. 4.87%; aHR, 0.77; 95% CI, 0.36-1.66; P = 0.50; Pinteraction = 0.07) or its individual components between bivalirudin and heparin groups. CONCLUSIONS Bivalirudin plus a post-PCI high-dose infusion was associated with significantly reduced 30-day composite rate of all-cause death or BARC types 3-5 bleeding compared with heparin monotherapy in STEMI patients undergoing primary PCI without GPI use. However, these benefits might be less pronounced in patients requiring bail-out GPI due to thrombotic complications during primary PCI. TRIAL REGISTRATION ClinicalTrials.gov NCT03822975.
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Affiliation(s)
- Jia Liao
- State Key Laboratory of Frigid Zone Cardiovascular Disease, Department of Cardiology, General Hospital of Northern Theater Command, Cardiovascular Research Institute, Shenyang, 110016, China
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Disease, Department of Cardiology, General Hospital of Northern Theater Command, Cardiovascular Research Institute, Shenyang, 110016, China
| | - Xiaojian Feng
- Department of Cardiology, Yueyang Central Hospital, Yueyang , Hunan, 414000, China
| | - Kui Chen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Dingbao Zhang
- Department of Cardiology, People's Hospital Of Pingchang County, Pingchang, Sichuan, 636400, China
| | - Yuncheng Zou
- Department of Cardiology, Yunnan St. John's Hospital, Kunming, 650000, China
| | - Xiaohui Zheng
- Department of Emergency, Fuwai Central China Cardiovascular Hospital, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital, Zhengzhou, 450000, China
| | - Gang Zhao
- Department of Cardiology, The First Hospital Of Liangshan, Xichang , Sichuan, 615000, China
| | - Nailiang Tian
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, China
| | - Zeqi Zheng
- Department of Cardiology, The First Affiliated Hospital Of Nanchang University, Nanchang, 330006, China
| | - Xiaoping Peng
- Department of Cardiology, The First Affiliated Hospital Of Nanchang University, Nanchang, 330006, China
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Zhenyang Liang
- State Key Laboratory of Frigid Zone Cardiovascular Disease, Department of Cardiology, General Hospital of Northern Theater Command, Cardiovascular Research Institute, Shenyang, 110016, China
| | - Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, Department of Cardiology, General Hospital of Northern Theater Command, Cardiovascular Research Institute, Shenyang, 110016, China.
| | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Disease, Department of Cardiology, General Hospital of Northern Theater Command, Cardiovascular Research Institute, Shenyang, 110016, China.
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, Zena and Michael A Wiener Cardiovascular Institute, New York, NY, USA
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Stone GW, Akinmolayemi O, Stables RH. Is bivalirudin ready for a comeback? Pros and cons. EUROINTERVENTION 2024; 20:e912-e914. [PMID: 39099374 PMCID: PMC11287373 DOI: 10.4244/eij-e-24-00013] [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] [Indexed: 08/06/2024]
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Kostromina MA, Tukhovskaya EA, Shaykhutdinova ER, Palikova YA, Palikov VA, Slashcheva GA, Ismailova AM, Kravchenko IN, Dyachenko IA, Zayats EA, Abramchik YA, Murashev AN, Esipov RS. Unified Methodology for the Primary Preclinical In Vivo Screening of New Anticoagulant Pharmaceutical Agents from Hematophagous Organisms. Int J Mol Sci 2024; 25:3986. [PMID: 38612796 PMCID: PMC11011928 DOI: 10.3390/ijms25073986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
The development of novel anticoagulants requires a comprehensive investigational approach that is capable of characterizing different aspects of antithrombotic activity. The necessary experiments include both in vitro assays and studies on animal models. The required in vivo approaches include the assessment of pharmacokinetic and pharmacodynamic profiles and studies of hemorrhagic and antithrombotic effects. Comparison of anticoagulants with different mechanisms of action and administration types requires unification of the experiment scheme and its adaptation to existing laboratory conditions. The rodent thrombosis models in combination with the assessment of hemostasis parameters and hematological analysis are the classic methods for conducting preclinical studies. We report an approach for the comparative study of the activity of different anticoagulants in vivo, including the investigation of pharmacodynamics and the assessment of hemorrhagic effects (tail-cut bleeding model) and pathological thrombus formation (inferior vena cava stenosis model of venous thrombosis). The reproducibility and uniformity of our set of experiments were illustrated on unfractionated heparin and dabigatran etexilate (the most common pharmaceuticals in antithrombic therapy) as comparator drugs and an experimental drug variegin from the tick Amblyomma variegatum. Variegin is notorious since it is a potential analogue of bivalirudin (Angiomax, Novartis AG, Basel, Switzerland), which is now being actively introduced into antithrombotic therapy.
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Affiliation(s)
- Maria A. Kostromina
- Laboratory of Biopharmaceutical Technologies, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia
| | - Elena A. Tukhovskaya
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Elvira R. Shaykhutdinova
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Yuliya A. Palikova
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Viktor A. Palikov
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Gulsara A. Slashcheva
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Alina M. Ismailova
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Irina N. Kravchenko
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Igor A. Dyachenko
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Evgeniy A. Zayats
- Laboratory of Biopharmaceutical Technologies, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia
| | - Yuliya A. Abramchik
- Laboratory of Biopharmaceutical Technologies, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia
| | - Arkady N. Murashev
- Biological Testing Laboratory, Branch of Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Pushchino, ProspektNauki, 6, 142290 Moscow, Russia
| | - Roman S. Esipov
- Laboratory of Biopharmaceutical Technologies, Shemyakin and Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, Miklukho-Maklaya Street, 16/10, 117997 Moscow, Russia
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Cohen M, Sohal S. Editorial: Bivalirudin versus unfractionated heparin in acute myocardial infarction: Why are we still debating? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:62-63. [PMID: 37980264 DOI: 10.1016/j.carrev.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Marc Cohen
- Section of Cardiovascular Medicine, Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ 07112, United States of America.
| | - Sumit Sohal
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
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Levy JH, Sniecinski RM. Reply to the letter to the editor regarding "Defining heparin resistance: communication from the ISTH SSC Subcommittee of Perioperative and Critical Care Thrombosis and Hemostasis". J Thromb Haemost 2024; 22:575-576. [PMID: 38309816 DOI: 10.1016/j.jtha.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/09/2023] [Indexed: 02/05/2024]
Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Galli M, Bernardi M, Ortega-Paz L, Nerla R, D'Amario D, Franchi F, Biondi-Zoccai G, Angiolillo DJ. Bivalirudin in acute coronary syndromes. Expert Rev Cardiovasc Ther 2023; 21:901-911. [PMID: 37919937 DOI: 10.1080/14779072.2023.2273902] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Bivalirudin, a bivalent direct thrombin inhibitor, has been developed to reduce bleeding without any trade-off in thrombotic events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). AREAS COVERED Despite showing a superior safety profile compared with unfractionated heparin (UFH), bivalirudin is not considered the anticoagulant of choice in ACS patients undergoing PCI, mainly because of an increased rate of acute stent thrombosis (ST) shown by several randomized controlled trials (RCTs), in addition to limited availability in certain countries and increased costs. However, RCTs on bivalirudin have been characterized by several confounding factors hindering the interpretation of its safety and efficacy compared with UFH among the spectrum of ACS patients. Furthermore, a significant body of evidence has demonstrated that the risk of acute ST can be mitigated by a full-dose infusion regimen following PCI, without compromising the favorable safety profile compared to UFH. EXPERT OPINION In light of the increased understanding of the prognostic relevance of bleeding events and the excellent safety profile of bivalirudin, recent trial evidence may allow for this anticoagulant agent to reemerge and have a more prominent role in the management of ACS patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Marco Bernardi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roberto Nerla
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Domenico D'Amario
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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