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Li X, Yu J, Wu X, Hu C, Wang X. Synthesis of 12-quinoline substituted andrographolide derivatives and their preliminary evaluation as anti-aggregation drugs. Aust J Chem 2023. [DOI: 10.1071/ch22248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Based on the structure of the natural product andrographolide, a series of novel 12-quinoline substituted derivatives 9 were designed and synthesized. In preliminary biological evaluation, these synthesized compounds showed prominent anti-platelet aggregation activities in response to thrombin and adenosine diphosphate (ADP) agonists. Among them, compound 9o (inhibition rate 55.73%, IC50 0.36 µM/L) had the highest anti-platelet aggregation activity induced by ADP. Compound 9q (inhibition rate 54.31%, IC50 0.30 µM/L) showed the highest anti-platelet aggregation activity induced by thrombin. Most of the derivatives had no significant cytotoxicity. Our research results provide a novel candidate drug structure for anti-platelet aggregation and enrich the scope of application of andrographolide derivatives.
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Sumarokov AB, Buryachkovskaya LI, Docenko YV, Kurochkin MS, Lomakin NV. Clinical Significance of Thrombin Blockade with Low Doses (2.5 mg) of Rivaroxaban in Ischemic Heart Disease Patients. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-01-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Arterial thrombosis is a result of complex interaction between blood cells, soluble coagulation factors in plasma and vessel wall. Antiplatelet drugs do not always provide the necessary antithrombotic effect of sufficient strength, because their influence does not extend to all three factors involved in this process. Low doses of direct oral inhibitors of thrombin are able to potentiate antithrombotic effect of antiplatelet therapy. The combination of rivaroxaban in a dose of 2.5 mg and standard double antiplatelet therapy turned out to be the most promising for clinical use, since studies with dabigatran and apixaban at the II and III stages of the trials were found to be unsuccessful due to the unacceptably high frequency of bleeding. Studies of the combination of rivaroxaban at a dose of 2.5 mg and standard antiplatelet therapy conducted in previous years among patients with acute myocardial infarction showed a decrease in the frequency of complications of atherothrombosis associated with their ischemic nature, while at the same time there was a slight increase in hemorrhagic complications. In the COMPASS study the combination of rivaroxaban (2.5 mg) plus aspirin reduced the risk of the primary endpoint (myocardial infarction, ischemic stroke, cardiovascular death) more significantly than aspirin alone in patients with stable ischemic heart disease and ischemic brain disease. The pathophysiological rationales for the use of low doses of rivaroxaban when added to dual antiplatelet therapy are considered, and the significance of recent studies in patients with acute coronary syndrome, stable ischemic heart disease and in the prevention of ischemic stroke is discussed.
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Affiliation(s)
| | | | | | - M. S. Kurochkin
- Central Clinical Hospital of the Presidential Administration of the Russian Federation
| | - N. V. Lomakin
- Central Clinical Hospital of the Presidential Administration of the Russian Federation
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Xiang Q, Pang X, Liu Z, Yang G, Tao W, Pei Q, Cui Y. Progress in the development of antiplatelet agents: Focus on the targeted molecular pathway from bench to clinic. Pharmacol Ther 2019; 203:107393. [PMID: 31356909 DOI: 10.1016/j.pharmthera.2019.107393] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 07/10/2019] [Indexed: 12/22/2022]
Abstract
Antiplatelet drugs serve as a first-line antithrombotic therapy for the management of acute ischemic events and the prevention of secondary complications in vascular diseases. Numerous antiplatelet therapies have been developed; however, currently available agents are still associated with inadequate efficacy, risk of bleeding, and variability in individual response. Understanding the mechanisms of platelet involvement in thrombosis and the clinical development process of antiplatelet agents is critical for the discovery of novel agents. The functions of platelets in thrombosis are regulated by two major mechanisms: the interaction between surface receptors and their ligands, and the downstream intracellular signaling pathways. Recently, most of the progress made in antiplatelet drug development has been achieved with P2Y receptor antagonists. Additionally, the usage of GP IIb/IIIa receptor antagonists has decreased, because it is associated with a higher risk of bleeding and thrombocytopenia. Agents targeting other platelet surface receptors such as PARs, TP receptor, EP3 receptor, GPIb-IX-V receptor, P-selectin, as well as intracellular signaling factors, such as PI3Kβ, have been evaluated in an attempt to develop the next generation of antiplatelet drugs, reduce or eliminate interpatient variability of drug efficacy and significantly lower the risk of drug-induced bleeding. The aim of this review is to describe the pathways of platelet activation in thrombosis, and summarize the development process of antiplatelet agents, as well as the preclinical and clinical evaluations performed on these agents.
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Affiliation(s)
- Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China
| | - Xiaocong Pang
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China
| | - Zhenming Liu
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Research Center of Drug Clinical Evaluation of Central South University, 138 TongZiPo Road, Changsha, Hunan 410013, China
| | - Weikang Tao
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Research Center of Drug Clinical Evaluation of Central South University, 138 TongZiPo Road, Changsha, Hunan 410013, China
| | - Qi Pei
- Shanghai Hengrui Pharmaceuticals Co., 279 Wenjing Road, Shanghai, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China.
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Cavallari I, Patti G. Clinical effects with inhibition of multiple coagulative pathways in patients admitted for acute coronary syndrome. Intern Emerg Med 2018; 13:1019-1028. [PMID: 29564693 DOI: 10.1007/s11739-018-1834-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 03/16/2018] [Indexed: 12/01/2022]
Abstract
Platelets and the coagulation cascade play key roles in initiation, amplification, and perpetuation of acute coronary syndromes (ACS). In the past few years, there has been great progress in ACS antithrombotic treatment with the introduction of novel anticoagulants (fondaparinux and bivalirudin), more potent P2Y12 inhibitors (prasugrel and ticagrelor) and protease-activated receptor antagonists (vorapaxar). Nonetheless, patients with ACS frequently have recurrent ischemic events despite the use of currently recommended dual antiplatelet therapy, revascularization procedures as appropriate, and other evidence-based secondary preventive measures. This is the rationale beyond intensification of antiplatelet therapy. However, the major downside of intensive antithrombotic therapy is bleeding. When treating ACS patients, clinicians should find the adequate balance between the reduction of thrombotic events by effective drug treatment and the induction of bleeding that is linked to the use of potent or multiple antithrombotic agents. Numerous antithrombotic cocktails including oral anticoagulants with or without aspirin have been tested in large clinical trials with the goal of further reduction of ischemia and bleeding risk. The aim of this review is to discuss clinical outcomes resulting from inhibition of multiple coagulative pathways in patients with ACS in light of evidence from large randomized controlled clinical trials.
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Affiliation(s)
- Ilaria Cavallari
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Giuseppe Patti
- Department of Cardiovascular Science, Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
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Perez-Rivera JA, Monedero-Campo J, Cieza-Borrella C, Ruiz-Perez P. Pharmacokinetic drug evaluation of vorapaxar for secondary prevention after acute coronary syndrome. Expert Opin Drug Metab Toxicol 2017; 13:339-350. [PMID: 28135897 DOI: 10.1080/17425255.2017.1289175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Vorapaxar is the first protease-activated receptor-1 inhibitor approved for clinical use. Its main indication is the reduction in thrombotic cardiovascular events in patients with previous myocardial infarction or symptomatic peripheral artery disease. Areas covered: This article reviews the pharmacokinetics of vorapaxar and its potential use in secondary prevention after an acute coronary syndrome. Expert opinion: Vorapaxar inhibits platelet aggregation mediated by thrombin. This effect is carried out without affecting to coagulation parameters and bleeding times. This drug has showed a significant reduction of cardiovascular events in patients with chronic atherosclerosis but not during the admission for an acute coronary syndrome. The rate of major bleeding found in patients treated with vorapaxar in randomized trials was consistently higher than placebo in most of the analyzed subgroups. For this reason, cautious evaluation of risk-benefit profiles should be required before prescribing this drug.
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Affiliation(s)
- Jose-Angel Perez-Rivera
- a Department of Cardiology , University Hospital of Burgos , Burgos , Spain.,b Universidad Isabel I , Burgos , Spain
| | | | - Clara Cieza-Borrella
- c Division of Genetics and Epidemiology , The Institute of Cancer Research , London , UK
| | - Pablo Ruiz-Perez
- a Department of Cardiology , University Hospital of Burgos , Burgos , Spain
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Ungar L, Rodriguez F, Mahaffey KW. Vorapaxar: emerging evidence and clinical questions in a new era of PAR-1 inhibition. Coron Artery Dis 2016; 27:604-15. [PMID: 27398626 DOI: 10.1097/mca.0000000000000409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite the use of therapies recommended in practice guidelines for secondary prevention in patients with atherosclerotic coronary artery disease, the residual risk for cardiovascular events remains high. Some of the residual risk is believed to result from incomplete platelet inhibition with current therapy. Vorapaxar is a first-in-class, novel antiplatelet agent that acts by antagonizing the PAR-1 receptor, inhibiting thrombin-mediated platelet activation. Vorapaxar was recently approved by the Food and Drug Administration for secondary prevention of cardiovascular events in patients with a history of myocardial infarction or peripheral artery disease who do not have a history of transient ischemic attack or stroke. We review the data from two key phase III cardiovascular outcome trials with vorapaxar: TRACER and TRA 2P-TIMI 50. We will focus on identifying the key patient populations that should be identified for treatment, highlight practical clinical issues when prescribing vorapaxar, and review unanswered questions. Vorapaxar should be considered in patients at high risk for recurrent ischemic events and low risk of bleeding.
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Affiliation(s)
- Leo Ungar
- aDepartment of Medicine bDivision of Cardiovascular Medicine and Stanford Center for Clinical Research, Stanford University, Stanford, California, USA
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Cheng JW. Impact of selective platelet inhibition in reducing cardiovascular risk - role of vorapaxar. Vasc Health Risk Manag 2016; 12:263-8. [PMID: 27366081 PMCID: PMC4913541 DOI: 10.2147/vhrm.s81342] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This article reviews the pharmacology, clinical efficacy, and safety of vorapaxar in reducing cardiovascular risk. Vorapaxar is a tricyclic himbacine-derived reversible inhibitor of platelet surface protease activator receptor-1, which prevents thrombin from activating platelets. Two Phase III clinical trials and multiple subanalyses from the two trials with vorapaxar have been published. In patients with recent acute coronary syndrome, vorapaxar, when added to standard therapy, did not reduce the composite cardiovascular end point. In contrary, in a study of secondary prevention for patients with cardiovascular diseases, vorapaxar reduced the risk of cardiovascular death or ischemic events (myocardial infarction, stroke) in patients with stable atherosclerosis who were receiving standard therapy. Vorapaxar is approved in the US for use with aspirin and/or clopidogrel in the secondary prevention of thrombogenic cardiovascular events in stable patients with peripheral arterial disease or a history of myocardial infarction. Vorapaxar increases risk of bleeding and is contraindicated in patients with previous cerebrovascular events. It is essential to balance individual patient’s bleeding risk to any further cardiovascular benefits that they may get. Future investigation is also needed to evaluate use of vorapaxar with newer antiplatelet agents such as ticagrelor and cangrelor, as well as its role as monotherapy.
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Affiliation(s)
- Judy Wm Cheng
- Department of Pharmacy Practice, MCPHS University, Boston, MA, USA
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Tan G, Chen J, Liu M, Yeh J, Tang W, Ke J, Wu W. Efficacy and safety of vorapaxar for the prevention of adverse cardiac events in patients with coronary artery disease: a meta-analysis. Cardiovasc Diagn Ther 2016; 6:101-8. [PMID: 27054099 DOI: 10.21037/cdt.2015.12.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide. Vorapaxar, a protease-activated receptor-1 (PAR-1) antagonist, is a novel antiplatelet agent that may provide us a new way in antithrombotic therapy. Several studies had been conducted to evaluate the efficacy of vorapaxar in the treatment of CAD, but the results were inconsistent. Here a meta-analysis was made to assess the efficacy and safety of vorapaxar in reducing adverse cardiac events in patients with CAD. METHODS A comprehensive literature search was conducted. The primary efficacy endpoint was the major adverse cardiac events, which was defined as a composite of cardiovascular death, myocardial infarction (MI), stroke, urgent coronary revascularization, or recurrent ischemia with rehospitalization. The primary safety endpoint was the composite of major or minor bleeding events. Pooled effects were measured by odds ratios (ORs) with 95% confidence intervals (CIs). A random-effect or fixed model was used in this meta-analysis. RESULTS Totally, 31,388 patients from four randomized controlled trials (RCTs) were included in this meta-analysis. Patients who took vorapaxar combined with standard dual anti-platelet therapy (aspirin and thienopyridine) showed a lower incidence in major adverse cardiac events (OR, 0.86, 95% CI: 0.75-0.99, P=0.03), MI (OR, 0.79, 95% CI: 0.67-0.95, P=0.01) and ischemic stroke (OR, 0.72, 95% CI: 0.58-0.89, P=0.003) than those who only took placebo instead. But there was no significant reduction in cardiovascular death (OR, 0.95, 95% CI: 0.82-1.09, P=0.45). Nevertheless, the vorapaxar group were associated with a higher risk of bleeding events (P<0.001). CONCLUSIONS The result of this meta-analysis indicated that adding vorapaxar to the standard dual anti-platelet therapy may be efficient in reducing the incidence of major adverse cardiac events at the cost of increasing risk of bleeding events.
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Affiliation(s)
- Guangyi Tan
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
| | - Jian Chen
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
| | - Mao Liu
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
| | - James Yeh
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
| | - Wenyi Tang
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
| | - Jianting Ke
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
| | - Wei Wu
- 1 Department of Cardiology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China ; 2 National Heart and Lung Institute, Imperial College London, London, UK ; 3 Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai 519000, China
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Kehinde O, Kunle R. Vorapaxar: A novel agent to be considered in the secondary prevention of myocardial infarction. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2016; 8:98-105. [PMID: 27134460 PMCID: PMC4832913 DOI: 10.4103/0975-7406.171690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 08/21/2015] [Accepted: 09/17/2015] [Indexed: 11/29/2022] Open
Abstract
Patients receiving therapy for the secondary prevention of myocardial infarction (MI) are still at high risk of a major cardiovascular event or death despite the use of currently available treatment strategy. Vorapaxar, an oral protease-activated receptor antagonist, is a novel antiplatelet drug that has been recently approved to provide further risk reduction. The results of two Phase III trials (thrombin receptor antagonists for clinical event reduction and the TRA 2°P-TIMI 50) have showed that vorapaxar, in addition to standard of care therapy, has the potential to provide further risk reduction in patients with prior MI. A search was made on PubMed on articles related to clinical trials and clinical consideration with the use of vorapaxar. This review article summarizes the results of Phase II trials, Phase III trials, subgroup analysis, precautions, and drug interaction with the use of vorapaxar.
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Affiliation(s)
- Obamiro Kehinde
- Division of Pharmacy, School of Medicine, University of Tasmania, Australia
| | - Rotimi Kunle
- Department of Pharmacology, College of Medicine, University of Lagos, Nigeria
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Feldman L, Steg PG, Amsallem M, Puymirat E, Sorbets E, Elbaz M, Ritz B, Hueber A, Cattan S, Piot C, Ferrières J, Simon T, Danchin N. Editor's Choice-Medically managed patients with non-ST-elevation acute myocardial infarction have heterogeneous outcomes, based on performance of angiography and extent of coronary artery disease. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:262-271. [PMID: 26758543 DOI: 10.1177/2048872615626354] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Medically managed individuals represent a high-risk group among patients with non-ST-elevation acute myocardial infarction (NSTE-AMI). We hypothesized that prognosis in this group is heterogeneous, depending on whether medical management was decided with or without coronary angiography (CAG). METHODS Using data from the French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction (FAST-MI), we analysed data from 798 patients with NSTE-AMI who were medically managed (i.e. without revascularization during the index hospitalization). Patients were categorized according to the performance of CAG and, if performed, to the extent of coronary artery disease (CAD). RESULTS There were marked differences in baseline demographics, according to whether CAG was performed and to the extent of CAD. While the overall mortality rate at five years was high (56.2%), it differed greatly between groups, with patients who did not undergo CAG having a higher mortality rate (77.4%) than patients who underwent CAG (36.7%, p<0.001), and a higher mortality rate even than patients with multivessel CAD (54.2%, p<0.001). By multivariable analysis, non-performance of CAG was an independent predictor of all-cause mortality among medically managed NSTE-AMI patients (adjusted hazard ratios (95% confidence intervals) 3.19 (1.79-5.67) at 30 days, 2.28 (1.60-3.26) at one year, and 1.63 (1.28-2.07) at five years; all p<0.001). CONCLUSION Medically managed patients with NSTE-AMI are a heterogeneous group in terms of baseline characteristics and outcomes. The highest risk patients are those who do not undergo CAG. Non-performance of CAG is a strong predictor of death. (FAST-MI, NCT00673036).
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Affiliation(s)
- Laurent Feldman
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France.,4 French Alliance for Cardiovascular Clinical Trials (FACT), France
| | - Philippe G Steg
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France.,5 Imperial College, Royal Brompton Hospital, London, UK
| | - Myriam Amsallem
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France
| | - Etienne Puymirat
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,6 Hôpital Européen Georges Pompidou, APHP, France.,7 Université Paris Descartes, France
| | - Emmanuel Sorbets
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France.,3 U1148, Institut National de la Santé et de la Recherche Médicale (INSERM) INSERM, France.,4 French Alliance for Cardiovascular Clinical Trials (FACT), France
| | - Meyer Elbaz
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,8 Hôpital Rangueil, Toulouse, France
| | | | | | - Simon Cattan
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,11 Hôpital Le Raincy-Montfermeil, France
| | | | | | - Tabassome Simon
- 3 U1148, Institut National de la Santé et de la Recherche Médicale (INSERM) INSERM, France.,4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,13 Département de Pharmacologie Clinique, Hôpital Saint-Antoine, APHP, France.,14 Université Pierre et Marie Curie, France
| | - Nicolas Danchin
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,6 Hôpital Européen Georges Pompidou, APHP, France.,7 Université Paris Descartes, France.,14 Université Pierre et Marie Curie, France
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Abstract
Dual antiplatelet therapy with aspirin, a platelet cyclooxygenase-1 inhibitor and P2Y12 receptor blockers, remains the major drug strategy to prevent ischemic event occurrence in patients with acute coronary syndromes and in patients undergoing coronary stenting, but there some limitations that can be overcome by targeting novel targets. Unlike direct thrombin inhibitors that bind directly to thrombin, targeting the platelet thrombin receptor, protease activated receptor (PAR)-1, may offer a better choice for the attenuation of atherosclerosis progression, thrombus-mediated ischemic events and restenosis without interfering with primary hemostasis. Vorapaxar - a synthetic analogue of himbacine, is a high affinity and highly selective PAR-1 antagonist that can effectively inhibit thrombin-induced platelet aggregation. In the TRACER trial, the addition of vorapaxar to standard therapy in patients with non-stent thrombosis-elevation- acute coronary syndromes did not significantly reduce the primary composite end point occurrence of cardiovascular (CV) death, myocardial infarction (MI), stroke, hospitalization for ischemia, or urgent revascularization, but significantly increased the GUSTO moderate and severe bleeding (p < 0.001) and intracranial hemorrhage (ICH). In the TRA 2°P-TIMI 50 trial, in patients with a history of MI and peripheral arterial disease (PAD) (67% of the total population), the end point of CV death, MI, or stroke was significantly (20%) reduced with vorapaxar whereas GUSTO moderate or severe bleeding was increased (1.5-fold), but not ICH or fatal bleeding and the net clinical outcome favoring the vorapaxar therapy. Based on these favorable results, the FDA approved vorapaxar for the reduction of thrombotic cardiovascular events in patients with prior MI or with PAD for long term therapy. A careful patient selection is needed to balance efficacy versus safety. At this time, patients with high risk for recurrent ischemic event occurrence such as patients with diabetes mellitus and previous MI can be safely treated with vorapaxar for long-term therapy.
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Affiliation(s)
- Udaya S Tantry
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA
| | - Fang Liu
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA.,b Department of Neurology , Beijing Hospital , Beijing 100730 , China
| | - Gailing Chen
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA.,c Department of Cardiology , China-Japan Friendship Hospital , Beijing 100029 , China
| | - Paul A Gurbel
- a "Inova Center for Thrombosis Research and Drug Development" Inova Heart and Vascular Institute , Fairfax , VA , USA
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Franchi F, Rollini F, Park Y, Angiolillo DJ. Platelet thrombin receptor antagonism with vorapaxar: pharmacology and clinical trial development. Future Cardiol 2015; 11:547-64. [PMID: 26406386 DOI: 10.2217/fca.15.50] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Oral antiplatelet therapies for secondary prevention of ischemic recurrences in patients with atherosclerotic disease manifestations include aspirin and P2Y12 receptor antagonists. Despite the use of these therapies, patients remain at risk for recurrent ischemic events, which may be attributed to other platelet signaling pathways which continue to be activated. More intense antithrombotic strategies have been investigated, including identifying additional targets to modulate platelet activation. Among these, thrombin-mediated platelet activation through PAR-1 has been subject to broad clinical investigation. Vorapaxar is the only PAR-1 receptor antagonists that completed large-scale clinical investigations and is approved for clinical use. This manuscript provides an overview of the pharmacology and clinical trial development of vorapaxar as well as its role in clinical practice.
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Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Yongwhi Park
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Dominick J Angiolillo
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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