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Polak D, Talar M, Wolska N, Wojkowska DW, Karolczak K, Kramkowski K, Bonda TA, Watala C, Przygodzki T. Adenosine Receptor Agonist HE-NECA Enhances Antithrombotic Activities of Cangrelor and Prasugrel in vivo by Decreasing of Fibrinogen Density in Thrombus. Int J Mol Sci 2021; 22:3074. [PMID: 33802928 PMCID: PMC8002731 DOI: 10.3390/ijms22063074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 02/04/2023] Open
Abstract
Blood platelets' adenosine receptors (AR) are considered to be a new target for the anti-platelet therapy. This idea is based on in vitro studies which show that signaling mediated by these receptors leads to a decreased platelet response to activating stimuli. In vivo evidence for the antithrombotic activity of AR agonists published to date were limited, however, to the usage of relatively high doses given in bolus. The present study was aimed at verifying if these substances used in lower doses in combination with inhibitors of P2Y12 could serve as components of dual anti-platelet therapy. We have found that a selective A2A agonist 2-hexynyl-5'-N-ethylcarboxamidoadenosine (HE-NECA) improved the anti-thrombotic properties of either cangrelor or prasugrel in the model of ferric chloride-induced experimental thrombosis in mice. Importantly, HE-NECA was effective not only when applied in bolus as other AR agonists in the up-to-date published studies, but also when given chronically. In vitro thrombus formation under flow conditions revealed that HE-NECA enhanced the ability of P2Y12 inhibitors to decrease fibrinogen content in thrombi, possibly resulting in their lower stability. Adenosine receptor agonists possess a certain hypotensive effect and an ability to increase the blood-brain barrier permeability. Therefore, the effects of anti-thrombotic doses of HE-NECA on blood pressure and the blood-brain barrier permeability in mice were tested. HE-NECA applied in bolus caused a significant hypotension in mice, but the effect was much lower when the substance was given in doses corresponding to that obtained by chronic administration. At the same time, no significant effect of HE-NECA was observed on the blood-brain barrier. We conclude that chronic administration of the A2A agonist can be considered a potential component of a dual antithrombotic therapy. However, due to the hypotensive effect of the substances, dosage and administration must be elaborated to minimize the side-effects. The total number of animals used in the experiments was 146.
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Affiliation(s)
- Dawid Polak
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
| | - Marcin Talar
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
| | - Nina Wolska
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
| | - Dagmara W. Wojkowska
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
| | - Kamil Karolczak
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
| | - Karol Kramkowski
- Department of Physical Chemistry, Medical University of Bialystok, Mickiewicza 2A, 15-089 Bialystok, Poland;
| | - Tomasz A. Bonda
- Department of General and Experimental Pathology, Medical University of Bialystok, Mickiewicza 2C, 15-222 Bialystok, Poland;
| | - Cezary Watala
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
| | - Tomasz Przygodzki
- Department of Haemostasis and Haemostatic Disorders, Chair of Biomedical Sciences, Medical University of Lodz, Mazowiecka 6/8, 92-235 Lodz, Poland; (D.P.); (M.T.); (N.W.); (D.W.W.); (K.K.); (C.W.)
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Bell H, Steinfort B, Pasalic L, Dexter M. Failure of platelet function analyser 200 to demonstrate clinical clopidogrel resistance in a patient undergoing intracranial vascular stenting. BMJ Case Rep 2020; 13:e233947. [PMID: 32169992 PMCID: PMC7069294 DOI: 10.1136/bcr-2019-233947] [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] [Accepted: 03/01/2020] [Indexed: 11/03/2022] Open
Abstract
A patient undergoes intracranial stent insertion for stent-assisted coiling of a basilar tip aneurysm and left middle cerebral artery aneurysm. A flow diverting stent is also placed across an anterior communicating artery aneurysm. Prior to the procedure, the patient takes dual antiplatelet medications, being aspirin and clopidogrel. Because of the concern regarding in-stent thrombus and thromboembolic complications related to intracranial stenting and the high rate of clopidogrel resistance, preoperative platelet function testing (PFT) was undertaken to ensure platelet inhibition. In this case, PFT was performed on a platelet function analyser which demonstrated platelet inhibition. Ten days following the procedure, the patient represented with thromboembolic stroke. Repeat PFT performed with whole blood impedance aggregometry and despite full medication compliance demonstrated clopidogrel resistance. Clopidogrel was then ceased and prasugrel commenced. This case demonstrates the importance of appropriate platelet inhibition in patients with intracranial stents and the controversy surrounding PFT.
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Affiliation(s)
- Hayden Bell
- Neurosurgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Brendan Steinfort
- Neurosurgery, Westmead Hospital, Sydney, New South Wales, Australia
- Neurosurgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Leonardo Pasalic
- Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Dexter
- Neurosurgery, Westmead Hospital, Sydney, New South Wales, Australia
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Bonney PA, Yim B, Brinjikji W, Walcott BP. Pharmacogenomic considerations for antiplatelet agents: the era of precision medicine in stroke prevention and neurointerventional practice. Cold Spring Harb Mol Case Stud 2019; 5:mcs.a003731. [PMID: 30936195 PMCID: PMC6549574 DOI: 10.1101/mcs.a003731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Antiplatelet drugs are widely utilized in the setting of primary stroke prevention, secondary stroke prevention, and neuroendovascular device-related stroke prevention. These medications are effective in general, although significant variability in drug activity exists between patients. Although this variation may be related in part to a multitude of factors, a growing body of evidence suggests that individual genotypes are a main contributor. The PharmGKB database was mined to prioritize genetic variants with potential clinical relevance for response to aspirin, clopidogrel, prasugrel, and ticagrelor. Although variants were reported for all drugs, the highest level of evidence was found in cytochrome P450 (CYP450) genotype variation related to clopidogrel response. Individual genetic influences have an impact on the pharmacodynamics of antiplatelet agents. Current clinical practice for stroke prevention is primarily empiric or guided by functional assays; however, there now exists a third potential pathway to base treatment decisions: genotype-guided treatment.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, University of Southern California, Los Angeles, California 90033, USA
| | - Benjamin Yim
- Department of Neurological Surgery, University of Southern California, Los Angeles, California 90033, USA
| | - Waleed Brinjikji
- Departments of Neurosurgery and Radiology, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Brian P Walcott
- Department of Neurological Surgery, University of Southern California, Los Angeles, California 90033, USA
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Divanji P, Shunk K. Modern Antiplatelet Therapy: When Is Clopidogrel the Right Choice? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Stavrou K, Koniari I, Gkizas V, Perperis A, Kontoprias K, Vogiatzi C, Bampouri T, Xanthopoulou I, Alexopoulos D. Ticagrelor vs prasugrel one-month maintenance therapy: Impact on platelet reactivity and bleeding events. Thromb Haemost 2017; 112:551-7. [DOI: 10.1160/th14-02-0119] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 03/25/2014] [Indexed: 11/05/2022]
Abstract
SummaryPlatelet reactivity (PR) and bleeding events following therapy with ticagrelor vs prasugrel have not been adequately studied. We aimed to compare PR and bleeding events in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) while on ticagrelor vs prasugrel for one month. Consecutive patients who were discharged either on ticagrelor 90 mg bid maintenance dose (MD) or prasugrel 10 mg MD were invited for PR assessment (VerifyNow, in PRU) at one month. High PR (HPR) was defined as >208 PRU. Bleeding events [Bleeding Academic Research Consortium (BARC) classification] were monitored. Out of 937 screened patients, 512 were analysed, 278 under ticagrelor MD and 234 under prasugrel MD. PR at 30 days (C-statistic of the propensity score model 0.63, 0.58–0.67 95% CI, p<0.001) was lower when on ticagrelor compared with prasugrel (33.3, 95% CI 29.3–37.3 vs 84.6, 95% CI 73.6–95.6, p<0.001). In the analysed population more BARC type 1 bleeding events were observed with ticagrelor compared to prasugrel (36.7% vs 28.2%, p=0.047). In 221 propensity score matched pairs, BARC type 1 bleeding rate was marginally higher in ticagrelor vs prasugrel treated patients (35.7% vs 27.1%, p=0.05). BARC type ≥2 events did not differ between groups 5 (2.3%) vs 5 (2.3%). HPR rate was higher for prasugrel-treated patients (5.4% vs 0%, p<0.001). In conclusion, in patients with ACS undergoing PCI, ticagrelor MD produces a significantly higher platelet inhibition compared to prasugrel MD. This pharmacodynamic difference might be associated with more nuisance bleeding events with ticagrelor use.Clinical Trial Registration ClinicalTrials.gov Identifier: NCT01774955.
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Su J, Yu Q, Zhu H, Li X, Cui H, Du W, Ji L, Tong M, Zheng Y, Xu H, Zhang J, Zhu Y, Xia Y, Liu T, Yao Q, Yang J, Chen X, Yu J. The risk of clopidogrel resistance is associated with ABCB1 polymorphisms but not promoter methylation in a Chinese Han population. PLoS One 2017; 12:e0174511. [PMID: 28358842 PMCID: PMC5373545 DOI: 10.1371/journal.pone.0174511] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 02/28/2017] [Indexed: 11/19/2022] Open
Abstract
The goal of our study was to investigate the contribution of ABCB1 expression to the risk of clopidogrel resistance (CR). Platelets functions were measured using the Verify-Now P2Y12 assay. Applying Polymerase Chain Reaction–Restriction Fragment Length Polymorphism (PCR-RFLP), the single-nucleotide polymorphisms (SNPs) was tested. Using bisulphite pyrosequencing assay, we investigated the association of the ABCB1 DNA methylation levels and CR. It was shown that female, hypertension, and lower albumin levels increased the risk of CR (P<0.05). If patients did not have hypoproteinaemia or had hypertension, the SNP in rs1045642 was associated with CR (CC vs. TT: albumin ≥35, P = 0.042; hypertension, P = 0.045; C vs. T: albumin ≥35, P = 0.033; hypertension, P = 0.040). Additionally, the platelet inhibition of the CT+TT genotype in rs1128503 was larger than that of the CC genotype (P = 0.021). Multivariate logistic regression analysis showed that male, higher albumin and hsCRP decreased the risk of CR, and the stent size maybe positively correlated with CR. The SNP in rs1045642 was related to all-cause mortality (P = 0.024). We did not find any relationship between the methylation levels of the ABCB1 promoter and CR. In conclusions, our study indicated that ABCB1 polymorphisms might be useful in further evaluating the pathogenesis of CR.
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Affiliation(s)
- Jia Su
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Qinglin Yu
- Department of Traditional Chinese Internal Medicine, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Hao Zhu
- Department of Anaesthesia, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Xiaojing Li
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Hanbin Cui
- Department of Cardiology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Weiping Du
- Department of Cardiology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Lindan Ji
- Department of Biochemistry, School of Medicine, Ningbo University, Ningbo, Zhejiang Province, People's Republic of China
| | - Maoqing Tong
- The Key Laboratory of Molecular Medicine, Ningbo No. 1 Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Yibo Zheng
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Hongyu Xu
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Jianjiang Zhang
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Yunyun Zhu
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Yezi Xia
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Ting Liu
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
| | - Qi Yao
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
- * E-mail: (QY); (JY); (XC); (JY)
| | - Jun Yang
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
- * E-mail: (QY); (JY); (XC); (JY)
| | - Xiaomin Chen
- Department of Cardiology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
- * E-mail: (QY); (JY); (XC); (JY)
| | - Jingbo Yu
- Department of Gerontology, Ningbo No.1 Hospital, Ningbo, Zhejiang Province, People's Republic of China
- * E-mail: (QY); (JY); (XC); (JY)
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Norgard NB, DiNicolantonio JJ. P2Y12 antagonists in non-ST-segment elevation acute coronary syndromes: latest evidence and optimal use. Ther Adv Chronic Dis 2015; 6:204-18. [PMID: 26137210 DOI: 10.1177/2040622315584113] [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: 01/31/2023] Open
Abstract
Dual antiplatelet therapy (DAPT), which includes the combination of aspirin and a P2Y12 platelet receptor inhibitor, is a well-established antiplatelet regimen in the treatment of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Three P2Y12 inhibitor options (clopidogrel, prasugrel and ticagrelor) are currently available, all having different efficacy and safety profiles along with contrasting contraindications, special warnings and precautions for use. This review compares and contrasts the unique P2Y12 antagonists in the NSTE-ACS setting, covering the latest evidence and their optimal use.
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Affiliation(s)
- Nicholas B Norgard
- University at Buffalo School of Pharmacy & Pharmaceutical Sciences, NYS Center of Excellence, Bioinformatics & Life Sciences, 701 Ellicott St, B3-322, Buffalo, NY 14203, USA
| | - James J DiNicolantonio
- Department of Preventive Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
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Cahoon WD, Kroll AL, Lowe DK. High On-Treatment Platelet Reactivity Associated With Prasugrel. J Pharm Technol 2015; 31:38-42. [DOI: 10.1177/8755122514545776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To report a case of high on-treatment platelet reactivity (HTPR) with prasugrel maintenance therapy despite adequate initial platelet response to a loading dose. Case Summary: A 51-year-old woman presented to the emergency department complaining of chest pain. She was diagnosed with acute-on-chronic systolic heart failure and non-ST-elevated myocardial infarction (MI). She had a previous MI with bare metal stent placement and was taking aspirin and prasugrel 10 mg daily. Once admitted, a P2Y12 assay revealed HTPR (331 PRU); therefore, prasugrel was reloaded (60 mg). The next day a P2Y12 assay showed adequate platelet reactivity inhibition (118 PRU), so prasugrel 10 mg daily was continued in the hospital and on discharge. Seventeen days after discharge she was readmitted for possible ischemia. On day 3 of admission, a P2Y12 assay revealed HTPR (278 PRU); subsequently, prasugrel was discontinued and ticagrelor started. After 3 doses of ticagrelor, a P2Y12 assay was 97 PRU, so ticagrelor was continued. Five months have passed since discharge. The patient continues to take ticagrelor and has had no further cardiac events. Discussion: HTPR indicates hypo- or nonresponsiveness for antiplatelet agents and may result in serious adverse events. HTPR has rarely been reported with prasugrel or ticagrelor. An objective causality assessment of our case revealed a probable association between HTPR and prasugrel. Conclusion: Patient education and recognition of signs and symptoms associated with prasugrel HTPR may prevent morbidity and mortality from treatment failure. Additional research may determine incidence, risk factors, and optimal management of HTPR with prasugrel.
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Affiliation(s)
| | - Amanda L. Kroll
- Virginia Commonwealth University Health Systems, Richmond, VA, USA
| | - Denise K. Lowe
- Virginia Commonwealth University Health Systems, Richmond, VA, USA
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Fernández-Rodríguez D, Brugaletta S, Otsuki S, Sabaté M. Acute Absorb bioresorbable vascular scaffold thrombosis in ST-segment elevation myocardial infarction: to stent or not to stent? EUROINTERVENTION 2014; 10:600; discussion 600. [DOI: 10.4244/eijv10i5a103] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Alexopoulos D. p2y12 receptor inhibitors in acute coronary syndromes: from the research laboratory to the clinic and vice versa. Cardiology 2014; 127:211-9. [PMID: 24458006 DOI: 10.1159/000357399] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022]
Abstract
The P2Y12 receptor plays a pivotal role in platelet activation and aggregation through a complex cascade of actions. Laboratory and clinical data have convincingly shown the benefit of P2Y12 inhibition combined with aspirin in patients with acute coronary syndrome (ACS)/undergoing percutaneous coronary intervention (PCI). Newer agents - like prasugrel, ticagrelor, and cangrelor - provide more consistent, faster, and stronger platelet inhibition than clopidogrel. In large clinical trials newer agents have resulted in fewer ischemic complications (though with increased bleeding potential) than clopidogrel. High-risk subpopulations like ST-segment elevation myocardial infarction, diabetes, chronic kidney disease, elderly, and low body weight patients have been identified. A 'return to the laboratory' has been observed recently, with several pharmacodynamic studies being performed particularly in these cohorts. This interplay between research laboratory and clinical data may lead to a more efficient and safer use of P2Y12 inhibitors.
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Fiore M, Horovitz A, Pons AC, Leroux L, Casassus F. First report of a subacute stent thrombosis in a prasugrel resistant patient successfully managed with ticagrelor. Platelets 2013; 25:636-8. [DOI: 10.3109/09537104.2013.852659] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Oprea AD, Popescu WM. ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly. J Cardiothorac Vasc Anesth 2013; 27:779-95. [DOI: 10.1053/j.jvca.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 02/02/2023]
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Alexopoulos D. Reloading patients chronically treated with P2Y12 inhibitors and presenting with ACS/PCI: facing a crossroad? Int J Cardiol 2013; 167:292-3. [PMID: 23063138 DOI: 10.1016/j.ijcard.2012.09.202] [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: 06/26/2012] [Revised: 09/23/2012] [Accepted: 09/26/2012] [Indexed: 11/18/2022]
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Di Dedda U, Ranucci M, Baryshnikova E, Castelvecchio S. Thienopyridines resistance and recovery of platelet function after discontinuation of thienopyridines in cardiac surgery patients. Eur J Cardiothorac Surg 2013; 45:165-70. [PMID: 23828846 DOI: 10.1093/ejcts/ezt279] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Patients who undergo cardiac operations under the effects of thienopyridines have a greater risk of major postoperative bleeding, transfusions and surgical revision due to bleeding. Discontinuation of thienopyridine is suggested but an adequate recovery period following discontinuation is still under debate, with opinions ranging from 3 to 7 days. The aim of this study was to assess the rate of recovery of thienopyridine-resistant patients and the time taken for resumption of platelet function after discontinuation of thienopyridine, in the setting of patients scheduled for cardiac operations. METHODS This was a retrospective study, based on 344 patients screened for platelet aggregation before cardiac operations. All the patients received thienopyridines within 7 days prior to the test. Multiple electrode aggregometry adenosine diphosphate test was used to assess platelet aggregation before the operation. RESULTS Thienopyridine resistance rate was 28%. Patients receiving clopidogrel had a significantly higher rate (32%) of resistance, compared with those receiving ticlopidine (14%) and thienopyridine resistance was significantly associated with platelet count (P = 0.006). The time taken to recover platelet function after thienopyridine discontinuation was variable between individuals; the only factor associated with a faster recovery time was the serum bilirubin value (P = 0.002). Platelet aggregation values high enough to avoid major bleeding were reached 3 days after discontinuation (95% confidence interval: 2-4 days); however, a complete recovery of platelet function was reached only after 8 days (95% confidence interval: 7-9 days). CONCLUSIONS Patient-specific factors determine the effectiveness of thienopyridine treatment and platelet function recovery rate. Among these, platelet count (for thienopyridine resistance) and serum bilirubin values (for platelet function recovery rate) should be considered.
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Affiliation(s)
- Umberto Di Dedda
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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Alexopoulos D, Xanthopoulou I. Letter by Alexopoulos et al regarding article, "pharmacodynamic effect of switching therapy in patients with high on-treatment platelet reactivity and genotype variation with high clopidogrel dose versus prasugrel: the RESET GENE Trial". Circ Cardiovasc Interv 2013; 6:e11. [PMID: 23424274 DOI: 10.1161/circinterventions.112.975953] [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: 11/16/2022]
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P2Y12 Receptor Inhibitors in Acute Coronary Syndromes: What Is New on the Horizon? Cardiol Res Pract 2013; 2013:195456. [PMID: 23533940 PMCID: PMC3590496 DOI: 10.1155/2013/195456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Accepted: 12/21/2012] [Indexed: 01/31/2023] Open
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor represents the cornerstone therapy for patients with acute coronary syndromes or undergoing percutaneous interventions, leading to a reduction of subsequent ischemic events. Variable response to clopidogrel has received close attention, and pharmacokinetic, pharmacodynamic, and pharmacogenomic factors have been identified as culprits. This led to the introduction of newer, potentially safer, and more effective antiplatelet agents (prasugrel and ticagrelor). Additionally, several point-of-care assays of platelet function have been developed in recent years to rapidly screen individuals on antiplatelet therapy. While the routine use of platelet function testing is uncertain and not currently recommended, it may be useful in instances when the degree of platelet inhibition may be uncertain such as high-risk patients undergoing percutaneous coronary intervention or when there may be a suspected pharmacodynamic interaction with other drugs. The current paper focuses on the P2Y12 receptor inhibitors and their pharmacogenetics and indications in patients with acute coronary syndromes or receiving percutaneous coronary interventions as well as the applicability of platelet function testing in this clinical context.
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Alexopoulos D, Xanthopoulou I, Plakomyti TE, Theodoropoulos KC, Mavronasiou E, Damelou A, Hahalis G, Davlouros P. Pharmacodynamic effect of prasugrel 5 mg vs clopidogrel 150 mg in elderly patients with high on-clopidogrel platelet reactivity. Am Heart J 2013; 165:73-9. [PMID: 23237136 DOI: 10.1016/j.ahj.2012.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 10/05/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Elderly patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) frequently exhibit high platelet reactivity (HPR) while on clopidogrel. In the elderly cohort, either prasugrel is not recommended or, if used, halving of the dose has been suggested. We aimed to test the hypothesis that in elderly patients exhibiting HPR after standard treatment with clopidogrel, prasugrel-reduced dose (5 mg) could be more effective than high-dose (150 mg) clopidogrel. METHODS Consecutive elderly (≥75 years old) patients with ACS undergoing PCI and loaded with clopidogrel were considered for platelet reactivity (PR) assessment at 24 hours after PCI with the VerifyNow assay (Accumetrics Inc, San Diego, CA), measured in P2Y12 reaction units (PRU). Of 63 screened patients, 30 (47.6%) were found with HPR (defined as PRU ≥230) and 27 of them participated in a prospective, randomized, single-center, single-blind, investigator-initiated, crossover study of platelet inhibition by prasugrel 5 mg/d vs clopidogrel 150 mg/d, with a 15-day treatment period. RESULTS The primary end point of PR at the end of the 2 study periods was lower in patients receiving low-dose prasugrel than those receiving high-dose clopidogrel (least squares estimates 190.8 [95% CI 161.5-220.1] and 240.8 [95% CI 211.0-270.6], respectively; P = .008). The secondary end point of HPR rate at the end of treatment periods was lower for prasugrel (8/24; 33.3%) compared with clopidogrel (16/24; 66.7%), P = .02. CONCLUSIONS In elderly patients with ACS undergoing PCI and exhibiting HPR after standard clopidogrel treatment, prasugrel 5 mg/d is significantly more efficacious than clopidogrel 150 mg/d in reducing PR and HPR rate.
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Prasugrel Versus High Dose Clopidogrel to Overcome Early High on Clopidogrel Platelet Reactivity in Patients with ST Elevation Myocardial Infarction. Cardiovasc Drugs Ther 2012; 26:393-400. [DOI: 10.1007/s10557-012-6407-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Jeong YH, Tantry US, Gurbel PA. Importance of potent P2Y(12) receptor blockade in acute myocardial infarction: focus on prasugrel. Expert Opin Pharmacother 2012; 13:1771-96. [PMID: 22783896 DOI: 10.1517/14656566.2012.704909] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Prasugrel therapy is recommended in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). AREAS COVERED This article reviews the efficacy and safety profile of prasugrel, cost considerations, and its role in clinical practice based on published data. The authors searched PubMed and Ovid databases for English language clinical trial articles involving the use of prasugrel in human subjects and patients, published through June 2012. The keyword "prasugrel" was used. The review focuses on clinical trials, but other articles including Food and Drug Administration documents are also reviewed. EXPERT OPINION Prasugrel has a more rapid and greater pharmacodynamic (PD) effect than clopidogrel. No significant drug - drug interactions have been reported. In a large-scale randomized clinical trial, prasugrel was associated with better protection against ischemic event occurrence compared to clopidogrel, but more bleeding in ACS patients undergoing PCI. Adverse outcomes outweighed the benefit of prasugrel in certain subgroups, including patients over the age of 75, those weighing less than 60 kg, and patients with a prior history of stroke or transient ischemic attack. In subsequent PD studies, prasugrel therapy showed suboptimal platelet inhibition in selected patients. In addition, "hyper-responsiveness" to prasugrel may increase the risk of serious bleeding in high-risk patients. More detailed studies are warranted to explore antiplatelet regimens tailored to optimally limit ischemic and bleeding event occurrences. A Phase-III TRILOGY trial (NCT00699998) will indicate the clinical efficacy and safety of prasugrel in patients with non-ST-segment elevation ACS, who are medically managed without coronary revascularization.
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Affiliation(s)
- Young-Hoon Jeong
- Sinai Center for Thrombosis Research, Cardiac Catherization Laboratories, 2401 W. Belvedere Ave, Baltimore, MD 21215, USA
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Alexopoulos D, Galati A, Xanthopoulou I, Mavronasiou E, Kassimis G, Theodoropoulos KC, Makris G, Damelou A, Tsigkas G, Hahalis G, Davlouros P. Ticagrelor Versus Prasugrel in Acute Coronary Syndrome Patients With High On-Clopidogrel Platelet Reactivity Following Percutaneous Coronary Intervention. J Am Coll Cardiol 2012; 60:193-9. [PMID: 22789884 DOI: 10.1016/j.jacc.2012.03.050] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 03/16/2012] [Indexed: 10/28/2022]
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Johansson PI, Sølbeck S, Genet G, Stensballe J, Ostrowski SR. Coagulopathy and hemostatic monitoring in cardiac surgery: an update. SCAND CARDIOVASC J 2012; 46:194-202. [PMID: 22375889 DOI: 10.3109/14017431.2012.671487] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) causes severe derangements in the hemostatic system, which in turn puts the patient at risks of microvascular bleeding. Excessive transfusion and surgical re-exploration after cardiac surgery are potentially associated with a number of adverse outcomes including increased mortality. DESIGN This review describes coagulopathies occurring in cardiac surgery and the monitoring of these. Viscoelastic hemostatic assays (VHA) have routinely been used in cardiac surgery for more than 25 years and at least 16 studies (involving more than 3250 patients, including three randomized controlled trials) have compared VHA to routine coagulation tests (RCoT) with regards to their ability to predict bleeding and re-do surgery and also with regards to transfusion requirements secondary to hemostatic therapy based on VHA vs. RCoT. RESULTS All 16 studies demonstrated superiority with VHA as compared to RCoT both in predicting bleeding and need for re-do surgery and in reducing the total amount of blood transfusions by employing goal-directed administration of blood products based on VHA as compared RCoT based therapy or at the clinicians discretion. CONCLUSIONS The different types of coagulopathies observed in patients undergoing cardiac surgery requires adequate and timely hemostatic therapy and real-time monitoring with WHA such as TEG/ROTEM and whole blood platelet aggregometry.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Denmark.
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Alexopoulos D, Panagiotou A, Xanthopoulou I, Komninakis D, Kassimis G, Davlouros P, Fourtounas C, Goumenos D. Antiplatelet effects of prasugrel vs. double clopidogrel in patients on hemodialysis and with high on-treatment platelet reactivity. J Thromb Haemost 2011; 9:2379-85. [PMID: 21985070 DOI: 10.1111/j.1538-7836.2011.04531.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND High on-treatment platelet reactivity (HTPR) is frequent in patients on hemodialysis (HD) receiving clopidrogel. OBJECTIVES The primary aim of this study was to determine the antiplatelet effects of prasugrel vs. high-dose clopidogrel in patients on HD with HTPR. PATIENTS/METHODS We performed a prospective, single-center, single-blind, investigator-initiated, randomized, crossover study to compare platelet inhibition by prasugrel 10 mg day(-1) with that by high-dose 150 mg day(-1) clopidogrel in 21 patients on chronic HD with HTPR. Platelet function was assessed with the VerifyNow assay, and genotyping was performed for CYP2C19*2 carriage. RESULTS The primary endpoint of platelet reactivity (PR, measured in P2Y12 reaction units [PRU]) was lower in patients receiving prasugrel (least squares [LS] estimate 156.6, 95% confidence interval [CI] 132.2-181.1) than in those receiving high-dose clopidogrel (LS 279.9, 95% CI 255.4-304.3), P < 0.001). The LS mean differences between the two treatments were - 113.4 PRU (95% CI - 152.9 to - 73.8, P < 0.001) and - 163.8 PRU (95% CI - 218.1 to - 109.2, P < 0.001) in non-carriers and carriers of at least one CYP2C19*2 allele, respectively. HTPR rates were lower for prasugrel than clopidogrel, in all patients (19% vs. 85.7%, P < 0.001) and in non-carriers (25.7% vs. 80%, P = 0.003). All carriers continued to show HTPR while receiving high-dose clopidogrel, but none showed it while receiving prasugrel. CONCLUSIONS In HD patients exhibiting HTPR following standard clopidogrel treatment, prasugrel 10 mg day(-1) is significantly more efficient than doubling the clopidogrel dosage in achieving adequate platelet inhibition. Neither effect seems to be influenced by carriage of the loss-of-function CYP2C19*2 allele.
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Affiliation(s)
- D Alexopoulos
- Department of Cardiology, Patras University Hospital, Patras, Greece.
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