Incidence, Predictors, and Clinical Impact of Early Prasugrel Cessation in Patients With ST-Elevation Myocardial Infarction

Incidence and impact of antiplatelet therapy cessation among very older patients with stable coronary artery disease

Objectives: Long-term use of evidence-based antiplatelet therapy is recommended for management of stable coronary artery disease (SCAD). However, non-adherence to antiplatelet drugs is common in older patients. This study aimed to evaluate the incidence and impact of antiplatelet therapy cessation on clinical outcomes of older patients with SCAD. Methods: A total of 351 consecutive eligible very older patients (≥80 years) with SCAD from the PLA General Hospital were included. Baseline demographics, clinical characteristics, and clinical outcomes were collected during follow-up. Patients were divided into cessation group and standard group based on whether discontinuing of antiplatelet drugs. The primary outcome was major adverse cardiovascular events (MACE) and secondary outcomes were minor bleeding and all-cause mortality. Results: A total of 351 participants, with a mean age of 91.76 ± 5.01 years old (range 80-106 years) were included in statistical analysis. The antiplatelet drug cessation rate was 60.1%. There were 211 patients in cessation group and 140 patients in standard group. During a median follow-up of 98.6 months, the primary outcome of MACE occurred in 155 patients (73.5%) in the cessation group and 84 patients (60.0%) in the standard group (HR = 1.476, 95% CI:1.124-1.938, p = 0.005). Cessation of antiplatelet drugs increased the rates of angina (HR = 1.724, 95% CI:1.211-2.453, p = 0.002) and non-fatal MI (HR = 1.569, 95% CI:1.093-2.251, p = 0.014). The secondary outcomes of minor bleeding and all-cause mortality were similar between the two groups. Conclusion: Among very older patients with SCAD, antiplatelet therapy cessation significantly increased the risk of MACE, and continuous antiplatelet drug therapy didn't increase the risk of minor bleeding.

Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis

AIM

Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full dose potent P2Y12 inhibitors in ACS patients who underwent PCI.

METHODS & RESULTS

PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched for eligible randomised controlled trials. Aspirin monotherapy trials were excluded. Five randomised trials (n = 10,779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1,242; platelet function guided to clopidogrel n = 1,304; unguided to clopidogrel n = 1,672; unguided to lower dose n = 1,170) versus standard DAPT (control group n = 5,391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥ 2 bleeding (HR 0.57, 95% CI 0.42-0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis and stroke (HR 0.77, 95% CI 0.62-0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies.

CONCLUSION

De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing, was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.

Antithrombotic treatment in primary percutaneous coronary intervention

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.

Frequency and Reasons of Dual Antiplatelet Therapy Discontinuation and Switching of P2Y12 Inhibitors in Patients with Acute Coronary Syndrome Treated with Stent Implantation

BACKGROUND

Incidence and reasons of dual antiplatelet therapy (DAPT) discontinuation and switching between P2Y12 inhibitors in acute coronary syndrome (ACS) patients treated with a stent have been poorly studied.

METHODS AND RESULTS

In a prospective single-center study, 283 consecutive patients presenting with ACS were treated with stent implantation between July 2015 and January 2016. Follow-up was achieved at 12 months in 273 patients using the electronic patient file and telephone interview. Switching from clopidogrel to a new antiplatelet agent (ticagrelor or prasugrel) or vice versa occurred in 60 (21.2%) patients. The most frequent reasons for switching were medical decisions not associated with bleeding events and concomitant use of chronic oral anticoagulation. Among the patients with a 1-year follow-up, 42 (15.4%) prematurely discontinued DAPT; 25 of them did so due to the need for an invasive procedure. DAPT premature discontinuation was not significantly associated with an increased 1-year risk of cardiovascular death or serious cardiac ischemic events (HR 2.08 [CI 95%: 0.88-4.94, p = 0.099]).

CONCLUSIONS

DAPT discontinuation and switching between P2Y12 inhibitors are not uncommon in patients with ACS treated with a stent. The most frequent reasons were the need for an invasive procedure and medical decisions.