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Lo ST, Li RHL, Georges CJ, Nguyen N, Chen CK, Stuhlmann C, Oldach MS, Rivas VN, Fousse S, Harris SP, Stern JA. Synergistic inhibitory effects of clopidogrel and rivaroxaban on platelet function and platelet-dependent thrombin generation in cats. J Vet Intern Med 2023; 37:1390-1400. [PMID: 37208839 PMCID: PMC10365033 DOI: 10.1111/jvim.16727] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/07/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Dual antithrombotic treatment (DAT) with clopidogrel and rivaroxaban sometimes is prescribed to cats with hypertrophic cardiomyopathy at risk of thromboembolism. To date, no studies have evaluated their combined effects on platelet function. OBJECTIVES/HYPOTHESIS Evaluate the safety of DAT in healthy cats and compare, ex vivo, platelet-dependent thrombin generation and agonist-induced platelet activation and aggregation in cats treated with clopidogrel, rivaroxaban, or DAT. We hypothesized that DAT would safely modulate agonist-induced platelet activation and aggregation more effectively than single agent treatment. ANIMALS Nine apparently healthy 1-year-old cats selected from a research colony. METHODS Unblinded, nonrandomized ex vivo cross-over study. All cats received 7 days of rivaroxaban (0.6 ± 0.1 mg/kg PO), clopidogrel (4.7 ± 0.8 mg/kg PO), or DAT with defined washout periods between treatments. Before and after each treatment, adenosine diphosphate (ADP)- and thrombin-induced platelet P-selectin expression was evaluated using flow cytometry to assess platelet activation. Platelet-dependent thrombin generation was measured by fluorescence assay. Platelet aggregation was assessed using whole blood impedance platelet aggregometry. RESULTS No cats exhibited adverse effects. Of the 3 treatments, only DAT significantly decreased the number of activated platelets (P = .002), modulated platelet activation in response to thrombin (P = .01), dampened thrombin generation potential (P = .01), and delayed maximum reaction velocity (P = .004) in thrombin generation. Like clopidogrel, DAT inhibited ADP-mediated platelet aggregation. However, rivaroxaban alone resulted in increased aggregation and activation in response to ADP. CONCLUSION AND CLINICAL IMPORTANCE Treatment combining clopidogrel and rivaroxaban (DAT) safely decreases platelet activation, platelet response to agonists, and thrombin generation in feline platelets more effectively than monotherapy with either clopidogrel or rivaroxaban.
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Affiliation(s)
- Sara T. Lo
- University of California Davis School of Veterinary MedicineWilliam R. Prichard Veterinary Medical Teaching HospitalDavisCaliforniaUSA
| | - Ronald H. L. Li
- Surgical and Radiological SciencesUniversity of California, DavisDavisCaliforniaUSA
| | - Catherine J. Georges
- University of California Davis School of Veterinary MedicineWilliam R. Prichard Veterinary Medical Teaching HospitalDavisCaliforniaUSA
| | - Nghi Nguyen
- Surgical and Radiological SciencesUniversity of California Davis School of Veterinary MedicineDavisCaliforniaUSA
| | - Cheyenne K. Chen
- Surgical and Radiological SciencesUniversity of California Davis School of Veterinary MedicineDavisCaliforniaUSA
| | - Claire Stuhlmann
- University of California Davis School of Veterinary MedicineWilliam R. Prichard Veterinary Medical Teaching HospitalDavisCaliforniaUSA
| | | | - Victor Noel Rivas
- Medicine and EpidemiologyUniversity of California Davis School of Veterinary MedicineDavisCaliforniaUSA
| | - Samantha Fousse
- University of California Davis School of Veterinary Medicine – VME, UC Davis 2108 Tupper Hall, One Shields AvenueDavis, California 95616‐5270USA
| | - Samantha P. Harris
- Cellular and Molecular Medicine, College of MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Joshua A. Stern
- Department of Medicine & EpidemiologyUniversity of California, Davis, 2108 Tupper Hall, One Shields AvenueDavis, California 95616USA
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Galli M, Franchi F, Rollini F, Ortega-Paz L, D'Amario D, De Caterina R, Mehran R, Gibson CM, Angiolillo DJ. Dual pathway inhibition in patients with atherosclerotic disease: pharmacodynamic considerations and clinical implications. Expert Rev Clin Pharmacol 2023; 16:27-38. [PMID: 36455906 DOI: 10.1080/17512433.2023.2154651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The persistence of elevated rates of ischemic recurrences despite the use of antiplatelet therapy among patients with atherosclerotic disease together with the understanding of the pivotal role of coagulation in the thrombo-inflammatory processes involved in the pathogenesis of atherosclerosis and its complications has fostered the development of treatments targeting both platelets and coagulation, a strategy known as dual-pathway inhibition (DPI). AREAS COVERED In this review we discuss the recent advancements in the understanding of the interplay between coagulation, platelets and inflammation involved in the pathophysiology of atherosclerosis and atherothrombosis, as the rationale for the implementation of a DPI strategy. We also discuss the available pharmacodynamic (PD) evidence and clinical implications with the use of DPI in patients with atherosclerotic disease. EXPERT OPINION The implementation of a DPI by adding the so-called 'vascular dose of rivaroxaban' (i.e. 2.5 mg bis in die), on top of antiplatelet therapy has consistently been associated with reduced levels of thrombin generation in PD studies and with reduced ischemic event rates at the cost of increased bleeding compared to antiplatelet therapy alone. Further research is warranted to best define patients in whom a DPI regimen has the best safety and efficacy profile.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Espinola-Klein C, Weißer G, Schmitt V, Schwaderlapp M, Munzel T. Antithrombotic therapy in peripheral arterial disease. Front Cardiovasc Med 2022; 9:927645. [PMID: 36312276 PMCID: PMC9606411 DOI: 10.3389/fcvm.2022.927645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Patients with peripheral arterial disease (PAD) are at increased risk for major adverse cardiovascular events (MACE) such as cardiovascular death, myocardial infarction, and stroke as well as major adverse limb events (MALE) such as amputation and acute limb ischemia. Therefore, prevention of thrombotic events is crucial to improve the prognosis of PAD patients. This review article concludes current evidence and guideline recommendations about antithrombotic therapy in PAD patients.Antithrombotic therapy is highly effective to reduce MACE and MALE events in PAD patients. Recently, the concept of dual pathway inhibition (low-dose rivaroxaban plus acetylic salicylic acid (ASA) has been tested in the COMPASS and VOYAGER-PAD trial. Compared to ASA alone dual pathway inhibition was superior to prevent MACE and MALE. After peripheral revascularization, in particular the risk for acute limb ischemia was reduced. In contrast, the risk for major bleeding is increased. Therefore, current guidelines recommend the combination of low-dose rivaroxaban and ASA in PAD patients with low bleeding risk. In patients with high bleeding risk, a single antiplatelet drug (preferable clopidogrel) is indicated. In patients with atherosclerotic vascular disease and indication for oral anticoagulation, no additional antiplatelet drug is necessary, as this would increase the risk of bleeding without improving the prognosis. Conclusion Antithrombotic treatment reduces MACE and MALE and is recommended in all patients with PAD. Individual bleeding risk should always be considered based on the current data situation and an individual benefit-risk assessment must be carried out.
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Affiliation(s)
- Christine Espinola-Klein
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany,*Correspondence: Christine Espinola-Klein
| | - Gerhard Weißer
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Volker Schmitt
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany,Center for Cardiology, Cardiology I–General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Schwaderlapp
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Munzel
- Center for Cardiology, Cardiology I–General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Willems LH, Thijssen DHJ, Groh LA, Kooijman NI, Ten Cate H, Spronk HMH, Donders ART, van der Vijver-Coppen RJ, van Hoek F, Nagy M, Reijnen MMPJ, Warlé MC. Dual pathway inhibition as compared to acetylsalicylic acid monotherapy in relation to endothelial function in peripheral artery disease, a phase IV clinical trial. Front Cardiovasc Med 2022; 9:979819. [PMID: 36277757 PMCID: PMC9583941 DOI: 10.3389/fcvm.2022.979819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/20/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Dual pathway inhibition (DPI) by combining acetylsalicylic acid (ASA) with low-dose rivaroxaban has been shown to reduce cardiovascular events in patients with peripheral arterial disease (PAD) when compared to ASA monotherapy. A potential explanation is that inhibition of factor Xa improves endothelial function through crosstalk between coagulation and inflammatory pathways, subsequently attenuating the occurrence of cardiovascular events. We hypothesize that the addition of rivaroxaban to ASA in PAD patients leads to improved endothelial function. Design An investigator-initiated, multicentre trial investigating the effect of DPI on endothelial function. Methods Patients, diagnosed with PAD, were enrolled in two cohorts: cohort A (Rutherford I-III) and cohort B (Rutherford IV-VI). Participants received ASA monotherapy for a 4-weeks run-in period, followed by 12 weeks of DPI. Macro- and microvascular endothelial dysfunction were studied by measuring carotid artery reactivity upon sympathetic stimulus and by measuring plasma endothelin-1 concentrations, respectively. All measurements were performed during the use of ASA (baseline) and after 12 weeks of DPI. Results 159 PAD patients (111 cohort A, 48 cohort B) were enrolled. Twenty patients discontinued study drugs early. Carotid artery constriction upon sympathetic stimulation at baseline (ASA) and after 12 weeks of DPI was similar in the total group, 22.0 vs. 22.7% (p = 1.000), and in the subgroups (Cohort A 22.6 vs. 23.7%, p = 1.000; cohort B 20.5 vs. 20.5%, p = 1.000), respectively. The mean concentration of plasma endothelin-1 at baseline and after 12 weeks of DPI did not differ, 1.70 ± 0.5 vs. 1.66 ± 0.64 pmol/L (p = 0.440) in the total group, 1.69 ± 0.59 vs. 1.62 ± 0.55 pmol/L in cohort A (p = 0.202), and 1.73 ± 0.53 vs. 1.77 ± 0.82 pmol/L in cohort B (p = 0.682), respectively. Conclusion Macro- and microvascular endothelial dysfunction, as reflected by carotid artery reactivity and plasma endothelin-1 concentrations, are not influenced in PAD patients by addition of low-dose rivaroxaban to ASA monotherapy for 12 weeks. Trial registration https://clinicaltrials.gov/ct2/show/NCT04218656.
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Affiliation(s)
- Loes H. Willems
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands,*Correspondence: Loes H. Willems
| | - Dick H. J. Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands,Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Laszlo A. Groh
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nina I. Kooijman
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hugo Ten Cate
- Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands,Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - Henri M. H. Spronk
- Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands
| | - A. Rogier T. Donders
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Frank van Hoek
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Magdolna Nagy
- Departments of Internal Medicine and Biochemistry, Maastricht University Medical Center (MUMC) and Cardiovascular Research Institute Maastricht (CARIM) School for Cardiovascular Diseases, Maastricht, Netherlands
| | - Michel M. P. J. Reijnen
- Department of Surgery, Rijnstate Hospital, Arnhem, Netherlands,Multi-Modality Medical Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Michiel C. Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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Khan H, Popkov M, Jain S, Djahanpour N, Syed MH, Rand ML, Eikelboom J, Mazer CD, Al-Omran M, Abdin R, Qadura M. Low-dose aspirin and rivaroxaban combination therapy to overcome aspirin non-sensitivity in patients with vascular disease. Front Cardiovasc Med 2022; 9:912114. [PMID: 36035952 PMCID: PMC9404329 DOI: 10.3389/fcvm.2022.912114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Approximately 20% of vascular patients treated with acetyl salicylic acid (i.e., aspirin) demonstrate less than expected platelet inhibition – putting them at a four-fold increased risk of adverse cardiovascular events. Low-dose rivaroxaban (2.5 mg twice daily) in combination with low-dose aspirin has been shown to reduce adverse cardiovascular and limb events when compared to aspirin alone. In this study, light transmission aggregometry was used to measure arachidonic acid-induced platelet aggregation to evaluate the potential of combining low-dose rivaroxaban and aspirin in attenuating or overcoming aspirin non-sensitivity. In the discovery phase, 83 patients with peripheral arterial disease (PAD) taking 81 mg aspirin daily were recruited from the outpatient vascular surgery clinic at St Michael's Hospital between January to September 2021. 19 (23%) were determined to be non-sensitive to aspirin. After ex-vivo addition of 2.5 mg dosage equivalent of rivaroxaban, aspirin non-sensitivity was overcome in 11 (58%) of these 19 patients. In the validation phase, 58 patients with cardiovascular risk factors who were not previously prescribed aspirin were recruited. In this group, ex-vivo addition of 2.5 mg dosage equivalent of rivaroxaban significantly reduced arachidonic acid-induced platelet aggregation in the presence of aspirin. These results demonstrate the potential for low-dose rivaroxaban to overcome aspirin non-sensitivity in patients with PAD. Further studies are needed to evaluate and confirm these findings.
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Affiliation(s)
- Hamzah Khan
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Mariya Popkov
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Shubha Jain
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Niousha Djahanpour
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Muzammil H Syed
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Margaret L Rand
- Department of Laboratory Medicine and Pathobiology, Biochemistry and Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Haematology/Oncology, Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Departments of Anesthesiology, Pain Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mohammad Qadura
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
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