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Reiner AP, Johnson AD. Platelet Genomics. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Máchal J, Hlinomaz O. Efficacy of P2Y12 Receptor Blockers After Myocardial Infarction and Genetic Variability of their Metabolic Pathways. Curr Vasc Pharmacol 2018; 17:35-40. [DOI: 10.2174/1570161116666180206110657] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/18/2017] [Accepted: 11/07/2017] [Indexed: 01/15/2023]
Abstract
Background: Various antiplatelet drugs are used following Acute Coronary Syndromes
(ACS). Of them, adenosine diphosphate receptor P2Y12 inhibitors clopidogrel, prasugrel and ticagrelor
are currently used for post-ACS long-term treatment. Although they act on the same receptor, they differ
in pharmacodynamics and pharmacokinetics. Several enzymes and transporters involved in the metabolism
of P2Y12 inhibitors show genetic variability with functional impact. This includes Pglycoprotein,
carboxylesterase 1 and, most notably, CYP2C19 that is important in clopidogrel activation.
Common gain-of-function or loss-of-function alleles of CYP2C19 gene are associated with lower
or higher platelet reactivity that may impact clinical outcomes of clopidogrel treatment. Prasugrel is
considered to be less dependent on CYP2C19 variability as it is also metabolized by other CYP450 isoforms.
Some studies, however, showed the relevance of CYP2C19 variants for platelet reactivity during
prasugrel treatment as well. Ticagrelor is metabolized mainly by CYP3A4, which does not show functionally
relevant genetic variability. Its concentrations may be modified by the variants of Pglycoprotein
gene ABCB1. While no substantial difference between the clinical efficacy of prasugrel
and ticagrelor has been documented, both of them have been shown to be superior to clopidogrel in
post-ACS treatment. This can be partially explained by lower variability at each step of their metabolism.
It is probable that factors influencing the pharmacokinetics of both drugs, including genetic factors,
may predict the clinical efficacy of antiplatelet treatment in personalized medicine.
</P><P>
Conclusion: We summarize the pharmacokinetics and pharmacogenetics of P2Y12 inhibitors with respect
to their clinical effects in post-myocardial infarction treatment.
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Affiliation(s)
- Jan Máchal
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Ota Hlinomaz
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
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Strisciuglio T, Franco D, Di Gioia G, De Biase C, Morisco C, Trimarco B, Barbato E. Impact of genetic polymorphisms on platelet function and response to anti platelet drugs. Cardiovasc Diagn Ther 2018; 8:610-620. [PMID: 30498685 DOI: 10.21037/cdt.2018.05.06] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiovascular genomic consists in the identification of polymorphic genes responsible for the susceptibility to cardiovascular disease including coronary artery disease (CAD). Genes involved in platelet activation and aggregation play a key role in the predisposition to CAD. A considerable inter-variability of platelet response to agonists and to drugs exists and in particular the hyper-reactivity phenotype seems to be heritable. Besides glycoproteins and receptors expressed on platelets surface whose mutations significantly impact on platelet function, moreover researchers in the last decades have paid great attention to the genes involved in the response to anti-platelet drugs, considering their pivotal role in the treatment and outcomes of CAD patients especially those undergoing PCI. With the outbreak of advanced techniques developed to analyse human genetic footprints, researchers nowadays have shifted from genetic linkage analysis and a candidate gene approach toward genome-wide association (GWAS) studies and the analysis of miRNA-mRNA expression profiles.
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Affiliation(s)
- Teresa Strisciuglio
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Danilo Franco
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Di Gioia
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Chiara De Biase
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Carmine Morisco
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno Trimarco
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Cameron SJ, Mix DS, Ture SK, Schmidt RA, Mohan A, Pariser D, Stoner MC, Shah P, Chen L, Zhang H, Field DJ, Modjeski KL, Toth S, Morrell CN. Hypoxia and Ischemia Promote a Maladaptive Platelet Phenotype. Arterioscler Thromb Vasc Biol 2018; 38:1594-1606. [PMID: 29724818 PMCID: PMC6023774 DOI: 10.1161/atvbaha.118.311186] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 04/17/2018] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Objective— Reduced blood flow and tissue oxygen tension conditions result from thrombotic and vascular diseases such as myocardial infarction, stroke, and peripheral vascular disease. It is largely assumed that while platelet activation is increased by an acute vascular event, chronic vascular inflammation, and ischemia, the platelet activation pathways and responses are not themselves changed by the disease process. We, therefore, sought to determine whether the platelet phenotype is altered by hypoxic and ischemic conditions. Approach and Results— In a cohort of patients with metabolic and peripheral artery disease, platelet activity was enhanced, and inhibition with oral antiplatelet agents was impaired compared with platelets from control subjects, suggesting a difference in platelet phenotype caused by the disease. Isolated murine and human platelets exposed to reduced oxygen (hypoxia chamber, 5% O2) had increased expression of some proteins that augment platelet activation compared with platelets in normoxic conditions (21% O2). Using a murine model of critical limb ischemia, platelet activity was increased even 2 weeks postsurgery compared with sham surgery mice. This effect was partly inhibited in platelet-specific ERK5 (extracellular regulated protein kinase 5) knockout mice. Conclusions— These findings suggest that ischemic disease changes the platelet phenotype and alters platelet agonist responses because of changes in the expression of signal transduction pathway proteins. Platelet phenotype and function should, therefore, be better characterized in ischemic and hypoxic diseases to understand the benefits and limitations of antiplatelet therapy.
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Affiliation(s)
- Scott J Cameron
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.) .,Division of Cardiology, Department of Medicine (S.J.C., C.N.M.)
| | - Doran S Mix
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Sara K Ture
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Rachel A Schmidt
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Amy Mohan
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Daphne Pariser
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Punit Shah
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - Lijun Chen
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - Hui Zhang
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - David J Field
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Kristina L Modjeski
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Sandra Toth
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Craig N Morrell
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.).,Division of Cardiology, Department of Medicine (S.J.C., C.N.M.)
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Kubica A, Obońska K, Fabiszak T, Kubica J. Adherence to antiplatelet treatment with P2Y12 receptor inhibitors. Is there anything we can do to improve it? A systematic review of randomized trials. Curr Med Res Opin 2016; 32:1441-51. [PMID: 27112628 DOI: 10.1080/03007995.2016.1182901] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary interventions. Non-adherence to medication after ACS may lead to increased morbidity, mortality, and costs to the healthcare system due to elevated risk of stent thrombosis, myocardial infarction or death. Medication adherence is an issue of growing concern regarding the improvement of health system performance. Promoting medication adherence offers a rare opportunity to simultaneously improve health outcomes while reducing costs of treatment in patients with coronary artery disease (CAD). The aim of this systematic review was to critically discuss adherence to antiplatelet treatment with P2Y12 receptor inhibitors in CAD patients. After a systematic investigation of the literature in databases including PubMed, CENTRAL and Google Scholar, using appropriate keywords, and considering clinical randomized, prospective observational and retrospective studies, reporting on adherence to treatment with inhibitors of P2Y12 platelet receptors or educational interventions aimed to improve medication adherence in patients with CAD, seven articles were considered eligible for inclusion in this systematic review. Reported adherence to clopidogrel, despite catastrophic consequences of its premature discontinuation, is low. We identified several determinants of low adherence and early discontinuation of clopidogrel. We also present data on the usefulness, utilization and credibility of different methods of medication adherence assessment, and suggest and critically discuss available interventions aimed at improvement of adherence to clopidogrel, still showing the need for innovative approaches to achieve enhanced medication adherence and improve health outcomes after acute myocardial infarction.
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Affiliation(s)
- Aldona Kubica
- a Department of Health Promotion, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Karolina Obońska
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Tomasz Fabiszak
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Jacek Kubica
- b Department of Cardiology and Internal Medicine, Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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Rafeedheen R, Bliden KP, Liu F, Tantry US, Gurbel PA. Novel Antiplatelet Agents in Cardiovascular Medicine. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:383. [DOI: 10.1007/s11936-015-0383-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Kubica A, Kasprzak M, Obońska K, Fabiszak T, Laskowska E, Navarese EP, Koziński M, Sztuba B, Świątkiewicz I, Grześk G, Kubica J. Discrepancies in assessment of adherence to antiplatelet treatment after myocardial infarction. Pharmacology 2015; 95:50-8. [PMID: 25592409 DOI: 10.1159/000371392] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 12/03/2014] [Indexed: 11/19/2022]
Abstract
The poor response to clopidogrel is multifactorial and includes, amongst others, low patient adherence to medication. The aim of this study was to assess the reported patient adherence to treatment with clopidogrel and confront it with adherence assessed by drug availability. We evaluated determinants of adherence and its impact on platelet aggregation and clinical outcome. The study population comprised 184 patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Follow-up visits were scheduled at 3, 6 and 9 months after discharge. Patient adherence to clopidogrel was defined according to self-reported drug intake and verified based on data from the National Health Fund regarding the purchase of prescribed drugs. The patients were judged as adherent when the proportion of drug availability exceeded 80%. According to drug availability, 100 (54.3%) patients were adherent and 84 (45.7%) were nonadherent. The analysis identified the following factors as predictors of low adherence (<80%): adenosine diphosphate-induced platelet aggregation (ADP-PA) during hospitalization ≤45 U, male gender and occurrence of ST-elevation myocardial infarction [(STEMI) vs. non-STEMI (NSTEMI)], while three-vessel disease was predictive of high adherence to medication. Compared with drug availability-based assessment, self-reported drug intake was significantly different: 172 (94.5%) patients reported regular and 10 (5.5%) patients reported irregular intake of clopidogrel. Clinical follow-up suggested that the self-reported nonregular clopidogrel intake may discriminate patients with a high risk of cardiovascular events. We demonstrated a huge discrepancy between the two most widely used methods for the evaluation of adherence to clopidogrel in secondary prevention treatment in patients after STEMI and NSTEMI. ADP-PA during hospitalization ≤45 U, male gender and STEMI (vs. NSTEMI) were independent predictors of nonadherence while three-vessel disease was independently predictive of adherence to treatment with clopidogrel in the investigated population.
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Affiliation(s)
- Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Kubica A, Kasprzak M, Siller-Matula J, Koziński M, Pio Navarese E, Obońska K, Andruszkiewicz A, Sztuba B, Fabiszak T, Swiątkiewicz I, Paciorek P, Kubica J. Time-related changes in determinants of antiplatelet effect of clopidogrel in patients after myocardial infarction. Eur J Pharmacol 2014; 742:47-54. [PMID: 25199965 DOI: 10.1016/j.ejphar.2014.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 08/14/2014] [Accepted: 08/18/2014] [Indexed: 01/20/2023]
Abstract
Substantial variability of antiplatelet action is an important limitation of clopidogrel. The aim of this study was to evaluate time-related changes in determinants of clopidogrel responsiveness in patients after myocardial infarction. The study population comprised 191 consecutive patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Follow-up visits were scheduled at 3, 6 and 9 months after discharge. ADP-induced platelet aggregation was tested with Multiplate Analyzer. Patients with ADP-PA>46.8U were defined as clopidogrel non-responders. The prevalence of clopidogrel non-responsiveness was highest during hospitalization and at 9 month follow-up visit, while it was lowest at 3 and 6 months after myocardial infarction (P=0.004). According to multivariate analysis, platelet count, mean platelet volume, concentration of hsCRP and leukocyte count influenced ADP-induced platelet aggregation in multiple assessment points. BMI, concentrations of hemoglobin, glycated hemoglobin, and BNP, hematocrit, adherence to medication, and patient׳s age were found to be independent predictors of high on-treatment ADP-induced platelet aggregation only at a single follow-up visit. Determinants of clopidogrel responsiveness in patients after myocardial infarction change within the long-term therapy. During hospitalization and early after discharge only biological factors affect ADP-induced platelet aggregation, while non-adherence to antiplatelet therapy may be a significant factor in determining clopidogrel non-responsiveness during late follow-up visits.
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Affiliation(s)
- Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, 3 Techników Street, 85-801 Bydgoszcz, Poland.
| | - Michał Kasprzak
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland; Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Jolanta Siller-Matula
- Department of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Marek Koziński
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Karolina Obońska
- Department of Pharmacology and Therapy, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland; Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland.
| | - Anna Andruszkiewicz
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, 3 Techników Street, 85-801 Bydgoszcz, Poland
| | - Beata Sztuba
- National Health Fund, 4A/30 Chołoniewskiego Street, 85-127 Bydgoszcz, Poland
| | - Tomasz Fabiszak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Iwona Swiątkiewicz
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Przemysław Paciorek
- Department of Emergency Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, 9M. Skłodowskiej-Curie Street, 85-094 Bydgoszcz, Poland
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Verdoia M, Cassetti E, Schaffer A, Di Giovine G, De Luca G. Platelet glycoprotein IIIa Leu33Pro gene polymorphism and coronary artery disease: A meta-analysis of cohort studies. Platelets 2014; 26:530-5. [PMID: 25167197 DOI: 10.3109/09537104.2014.948839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Great interest has been focused in the last year on genetic predictors of cardiovascular risk. Glycoprotein IIb/IIIa (GP IIb/IIIa), fibrinogen receptor, is the final common pathway for aggregation and a key point for atherothrombosis. A single nucleotide polymorphism of IIIa subunit (Leu33Pro-PlA(1)/PlA(2) allele) has been suggested to increase aggregation and adhesion, however, contrasting reports have been reported so far on its effects on coronary artery disease (CAD). Aim of the current study was to perform a large meta-analysis including cohorts of patients undergoing coronary angiography in order to evaluate whether this polymorphism is associated with coronary artery disease. Literature archives (Pubmed, EMBASE, Cochrane) and main scientific sessions abstracts were scanned for data of consecutive cohorts of patients undergoing coronary angiography, where PlA genotype was assessed. Primary endpoint was the prevalence of CAD. Secondary endpoint was severity of CAD defined as prevalence of multivessel disease (≥2 vessels). Data from seven studies were extracted, including a final number of 6700 patients. Among them 1893 (28.3%) carried the PlA(2) polymorphism, 163 of them in homozygosis. Angiographically defined CAD was present in 3573 (74.3%) PlA(1)/PlA(1) patients and in 1430 (75.5%) PlA(2) carriers. PlA(2) polymorphism was not associated with an increased prevalence of coronary artery disease, (OR [95% CI] = 1.07 [0.95-1.21], p = 0.28, pheterogeneity = 0.39). Similar results were obtained for multivessel disease (OR [95% CI] = 1.07[0.95-1.20], p = 0.27, pheterogeneity = 0.12). Meta-regression analysis demonstrated a significant inverse relationship between the risk of CAD among the PlA(2) carriers and ageing (r = -0.044, (-0.09, -0.0008), p = 0.046). Present meta-analysis demonstrates that 33Leu → Pro substitution of GPIIIa does not influence the prevalence and extent of angiographically defined coronary artery disease in general population, although apparently playing a role among younger patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University , Novara , Italy
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Update: Acute coronary syndromes (V). Personalized antiplatelet therapy. ACTA ACUST UNITED AC 2014; 67:480-7. [PMID: 24863597 DOI: 10.1016/j.rec.2014.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 01/20/2014] [Indexed: 11/22/2022]
Abstract
It is well established that high on-treatment platelet reactivity to adenosine diphosphate during clopidogrel therapy is an independent risk factor for ischemic event occurrences in a postpercutaneous coronary intervention patients. However, the precise role of platelet function testing remains debated. Platelet function testing to ensure optimal platelet inhibition has been recommended by some authorities to improve outcomes in patients treated with clopidogrel. Recent prospective, randomized trials of personalized antiplatelet therapy have failed to demonstrate a benefit of platelet function testing in improving outcomes. In this review article, we discuss the mechanisms responsible for clopidogrel nonreponsiveness, recent trials of platelet function testing, and other new developments in the field of personalized antiplatelet therapy.
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Kubica J, Kozinski M, Navarese EP, Tantry U, Kubica A, Siller-Matula JM, Jeong YH, Fabiszak T, Andruszkiewicz A, Gurbel PA. Cangrelor: an emerging therapeutic option for patients with coronary artery disease. Curr Med Res Opin 2014; 30:813-28. [PMID: 24393016 DOI: 10.1185/03007995.2014.880050] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To perform a systematic up-to-date review and critical discussion of potential clinical applications of cangrelor based on its pharmacologic properties and the main findings from randomized clinical studies. METHODS A database search (PubMed, CENTRAL and Google Scholar) by two independent investigators, including proceedings from scientific sessions of ACC, AHA, ESC, TCT and EuroPCR, from January 1998 through December 2013. RESULTS Cangrelor is a potent, intravenous, direct-acting P2Y12 antagonist with rapid onset and quickly reversible action. In contrast to ticagrelor, cangrelor's interaction with thienopiridines requires termination of cangrelor infusion before switching to clopidogrel or prasugrel. According to randomized trials, a cangrelor-clopidogrel combination is relatively safe and more effective than the standard clopidogrel regimen in both urgent and elective percutaneous coronary intervention (PCI) settings, with the advantage of this drug combination fully evident when the universal definition of myocardial infarction is applied. In contrast to available antiplatelet drugs with delayed onset and offset of action, its favorable properties make cangrelor a desirable agent for ad hoc elective PCI, high risk acute coronary syndromes treated with immediate coronary stenting and for bridging those surgery patients who require periprocedural P2Y12 inhibition. Current evidence on cangrelor therapy is limited by the lack of adequately powered studies assessing cangrelor co-administration either with prasugrel or ticagrelor, suboptimal design of some of the trials favoring cangrelor, potentially attenuated benefits with modern stent design, and finally, by the lack of survival advantage. CONCLUSIONS With its pharmacokinetic and pharmacodynamic advantages, allowing consistent and strong P2Y12 inhibition, and with its rapid onset and swift reversal of action devoid of need for an antidote, cangrelor might improve clinical outcomes in clopidogrel-treated patients by reducing ischemic events, while maintaining a favorable safety profile. However, further studies, addressing the safety and efficacy of cangrelor on top of novel oral P2Y12 inhibitors, are warranted.
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Affiliation(s)
- Jacek Kubica
- Collegium Medicum, Nicolaus Copernicus University , Bydgoszcz , Poland
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Erlinge D, James S, Duvvuru S, Jakubowski JA, Wagner H, Varenhorst C, Tantry US, Brown PB, Small D, Moser BA, Sundseth SS, Walker JR, Winters KJ, Gurbel PA. Clopidogrel metaboliser status based on point-of-care CYP2C19 genetic testing in patients with coronary artery disease. Thromb Haemost 2014; 111:943-50. [PMID: 24402637 DOI: 10.1160/th13-09-0767] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 11/26/2013] [Indexed: 01/27/2023]
Abstract
We compared results obtained with the Nanosphere Verigene® System, a novel point-of-care (POC) genetic test capable of analysing 11 CYP2C19 variants within 3 hours, to an established, validated genotyping method (Affymetrix™ DMET+; reference assay) for identifying extensive and reduced metabolisers of clopidogrel. Based on genotyping, patients (N=82) with stable coronary artery disease on clopidogrel 75 mg daily were defined as extensive metabolisers (*1/*1, *1/*17, *17/*17), reduced metabolisers (*1/*2, *1/*8, *2/*2, *2/*3), or of indeterminate metaboliser status (*2/*17). Pharmacokinetic exposure to clopidogrel's active metabolite and pharmacodynamic measures with P2Y12 reaction units (PRU) (VerifyNow®P2Y12 assay) and VASP PRI (PRI) were also assessed. There was a 99.9% overall concordance of marker-level data between the Nanosphere Verigene and DMET+ systems in identifying the CYP2C19 variants and 100% agreement in classifying the patients as extensive (n=59) or reduced metabolisers (n=15). Extensive metabolisers had significantly higher active metabolite exposure than reduced metabolisers (LS means 12.6 ng*h/ml vs 7.7 ng*h/ml; p<0.001). Extensive metabolisers also had lower PRU (LS means 158 vs 212; p=0.003) and VASP PRI (LS means 48% vs 63%, p=0.01) compared to reduced metabolisers. Rates of high on-treatment platelet reactivity were higher in reduced metabolisers compared to extensive metabolisers (VASP PRI ≥ 50%: 79% vs 47%; PRU >235: 33% vs 16%). The Nanosphere Verigene CBS system identified 11 CYP2C19 alleles in less than 3 hours with a high degree of accuracy when compared to a conventional method, and was further validated against pharmacokinetic and pharmacodynamic phenotypes.
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Affiliation(s)
- David Erlinge
- David Erlinge, Dept. of Cardiology, Lund University, Skane University Hospital, Lund; 221 85 Lund, Sweden, Tel: +46 46172597, Fax: +46 46157857, E-mail:
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Gurwitz D. Personalizing Anticoagulant and Antiplatelet Therapeutics: A Timely Task. Drug Dev Res 2013. [DOI: 10.1002/ddr.21096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David Gurwitz
- Department of Human Molecular Genetics and Biochemistry; Sackler Faculty of Medicine; Tel-Aviv University; Tel-Aviv; 69978; Israel
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Gorelick PB, Farooq MU. Advances in our understanding of "resistance" to antiplatelet agents for prevention of ischemic stroke. Stroke Res Treat 2013; 2013:727842. [PMID: 23936730 PMCID: PMC3725785 DOI: 10.1155/2013/727842] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/27/2013] [Indexed: 01/10/2023] Open
Abstract
We review the role of aspirin and clopidogrel for prevention of ischemic stroke and explore the concept of antiplatelet therapy resistance both from a laboratory and clinical perspective and genetic polymorphisms that might influence platelet reactivity with clopidogrel administration. Debates have raged over the years about the application of platelet function tests in clinical practice. We conclude that platelet function testing is not indicated in routine clinical practice. This recommendation is supported by clinical guideline statements, a lack of a global platelet function measure, and limitations of current platelet function test methods as applied in practice. We discuss a recently hypothesized hierarchy of patient characteristics in relation to which patients are most likely to benefit from platelet function studies based on acuity (i.e., risk) of cardiovascular disease. A focus of antiplatelet therapy administration should include emphasis on compliance/adherence and in the example of aspirin, use of well-absorbed forms of aspirin and avoidance of drugs that may interact with aspirin to inhibit its mechanism of action (e.g., certain nonsteroidal anti-inflammatory drugs).
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Affiliation(s)
- Philip B. Gorelick
- Hauenstein Neuroscience Center, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
- Department of Translational Science and Molecular Medicine, Michigan State University College of Human Medicine, 333 Bostwick Avenue NE, Grand Rapids, MI 49503, USA
| | - Muhammad U. Farooq
- Hauenstein Neuroscience Center, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
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