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Rubboli A, Atar D, Sibbing D. De-escalation of antithrombotic treatment after acute coronary syndrome, a new paradigm. Intern Emerg Med 2024:10.1007/s11739-024-03590-y. [PMID: 38594458 DOI: 10.1007/s11739-024-03590-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/19/2024] [Indexed: 04/11/2024]
Abstract
After an acute coronary syndrome (ACS) it is imperative to balance the bleeding vs. the ischemic risk given the similar prognostic impact of the two events. Since the post-discharge bleeding risk is substantially stable over time whereas the ischemic risk accumulates in the first weeks to months, a strategy of de-escalation of antithrombotic treatment, consisting in the reduction of either the duration (i.e., early interruption of one antiplatelet agent) or the intensity (i.e., switching from the more potent P2Y12-inhibitors prasugrel or ticagrelor to clopidogrel) of dual antiplatelet therapy (DAPT), has been proposed. Reducing the intensity of DAPT can be carried out as a default strategy (unguided approach) or based on the results of either platelet function tests or genetic tests (guided approach). Overall, all de-escalation strategies have shown to consistently decrease bleeding events with no apparent increase in ischemic events as compared to 12-month standard-of-care DAPT. Owing however to several limitations and weaknesses of the available evidence, de-escalation strategies are currently not recommended as a routine, but should rather be considered for selected ACS patients, such as those at increased risk of bleeding.
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Affiliation(s)
- Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Viale Randi 5, 48121, Ravenna, Italy.
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf, Germany
- Department of Cardiology, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany
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2
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Galli M, Occhipinti G. "Ticking away the moments that make up a dull DAPT course": Time matters. Int J Cardiol 2024; 398:131424. [PMID: 37820780 DOI: 10.1016/j.ijcard.2023.131424] [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: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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3
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Galli M, Laborante R, Occhipinti G, Zito A, Spadafora L, Biondi-Zoccai G, Nerla R, Castriota F, D'Amario D, Capodanno D, Jeong YH, Kimura T, Mehran R, Angiolillo DJ. Impact of ethnicity on antiplatelet treatment regimens for bleeding reduction in acute coronary syndromes: a systematic review and pre-specified subgroup meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:158-169. [PMID: 37960983 DOI: 10.1093/ehjcvp/pvad085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 11/15/2023]
Abstract
AIMS Randomized controlled trials (RCTs) testing bleeding reduction strategies using antiplatelet treatment regimens (BRATs) in acute coronary syndromes (ACS) have shown promising results, but the generalizability of these findings may be significantly influenced by the ethnicity of the patients enrolled, given that East Asian (EA) patients show different ischaemic-bleeding risk profile compared to non-EA patients. METHODS AND RESULTS RCTs comparing a BRAT vs. standard 12-month dual antiplatelet therapy (DAPT) in patients with ACS undergoing percutaneous coronary intervention (PCI) were selected. The primary efficacy endpoint was major adverse cardiovascular events (MACE) as defined in each trial and the primary safety endpoint was minor or major bleeding. Twenty-six RCTs testing seven different BRATs were included. The only strategy associated with a trade-off in MACE was 'upfront unguided de-escalation' in the subgroup of non-EAs (risk ratio 1.16, 95% confidence interval 1.09-1.24). All but aspirin monotherapy-based strategies (i.e. 'short and very short DAPT followed by aspirin') were associated with reduced bleeding compared with standard DAPT in both EA and non-EA patients. There were no significant differences between subgroups, but the lack of RCTs in some of the included strategies and the difference in the certainty of evidence between EA and non-EA patients revealed that the evidence in support of different BRATs in ACS undergoing PCI is influenced by ethnicity. Moreover, absolute risk reduction estimation revealed that some BRATs might be more effective than others in reducing bleeding according to ethnicity. CONCLUSION The majority of BRATs are associated with reduced bleeding without any trade-off in hard ischaemic endpoints regardless of ethnicity. However, the supporting evidence and relative safety profiles of different BRATs might be significantly affected by ethnicity, which should be taken into account in clinical practice. STUDY REGISTRATION This study is registered in PROSPERO (CRD42023416710).
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, Catania, Italy
| | - Andea Zito
- Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Spadafora
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Roberto Nerla
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Domenico D'Amario
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, Catania, Italy
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Voicu V, Diehm N, Moarof I, Parejo S, Badiqué F, Burden A, Niedrig D, Béchir M, Russmann S. Antiplatelet therapy guided by CYP2C19 point-of-care pharmacogenetics plus multidimensional treatment decisions. Pharmacogenomics 2024; 25:5-19. [PMID: 38230622 DOI: 10.2217/pgs-2023-0200] [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] [Indexed: 01/18/2024] Open
Abstract
Aim: Implementation of CYP2C19 point-of-care (POC) pharmacogenetic (PGx) testing with personalized treatment recommendations. Methods: POC CYP2C19 genotyping plus expert evaluation of risk factors for ischemic and bleeding events. Results: 167 patients underwent PGx testing, 54 (32.3%) were CYP2C19 loss of function carriers, and POC versus standard PGx analysis results for *2 and *3 variants matched in 100%. Antiplatelet therapy was adjusted in 44 patients (26.3%), but always required consideration of patient-specific factors. Conclusion: CYP2C19 POC-PGx is reliable and offers clinically relevant advantages for immediate evidence-based adaptations of antiplatelet therapy, whereas in less acute cases conventional PGx testing can also have advantages. Antiplatelet therapy has become more complex, and implementation of PGx-based personalized antiplatelet therapy requires complementary expert knowledge.
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Affiliation(s)
- Victor Voicu
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
| | - Nicolas Diehm
- Center for Vascular Medicine, 5000, Aarau, Switzerland
| | - Igal Moarof
- Cardiology Center Mittelland, 5001, Aarau, Switzerland
| | - Sarah Parejo
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Florent Badiqué
- Medical Genetics Laboratory, Labor Risch, 3097, Berne-Liebefeld, Switzerland
| | - Andrea Burden
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
| | - David Niedrig
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Hospital Pharmacy, Clinic Hirslanden Zurich, 8032, Zurich, Switzerland
| | - Markus Béchir
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
| | - Stefan Russmann
- Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
- drugsafety.ch, 8700 Küsnacht ZH, Switzerland
- Center for Internal Medicine, Hirslanden Clinic Aarau, 5001 Aarau, Switzerland
- University of Nicosia Medical School, 2408, Nicosia-Egkomi, Cyprus
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5
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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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6
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Galli M, Andreotti F, Sabouret P, Gragnano F. 2023 ESC Guidelines on ACS: what is new in antithrombotic therapy? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:595-596. [PMID: 37738449 DOI: 10.1093/ehjcvp/pvad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/07/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Catholic University Medical School, 00168 Rome, Italy
| | - Pierre Sabouret
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, 75013 Paris, France
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 81055 Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", 81100 Caserta, Italy
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Cacciatore S, Spadafora L, Bernardi M, Galli M, Betti M, Perone F, Nicolaio G, Marzetti E, Martone AM, Landi F, Asher E, Banach M, Hanon O, Biondi-Zoccai G, Sabouret P. Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence. J Clin Med 2023; 12:5233. [PMID: 37629275 PMCID: PMC10455820 DOI: 10.3390/jcm12165233] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.
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Affiliation(s)
- Stefano Cacciatore
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Matteo Betti
- University of Milan, 20122, Milan, Italy
- Monzino IRCCS Cardiological Center, 20137 Milan, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, 81020 Castel Morrone, Caserta, Italy
| | - Giulia Nicolaio
- Department of Experimental and Clinical Medicine and Geriatrics, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Anna Maria Martone
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Elad Asher
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, P.O. Box 12271, Jerusalem 9112102, Israel
| | - Maciej Banach
- Department of Preventive Cardiology, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Medical University of Lodz (MUL), 93-338 Lodz, Poland
| | - Olivier Hanon
- Assistance Publique Hôpitaux de Paris, Geriatric Department, Broca Hospital, University of Paris Cité, 54–56 Rue Pascal, 75013 Paris, France
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, Via Orazio 2, 80122 Naples, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, ACTION-Group, Sorbonne University, 47–83 Bd de l’Hôpital, 75013 Paris, France
- Department of Cardiology, National College of French Cardiologists, 13 Rue Niépce, 75014 Paris, France
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8
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [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] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Galli M, Bernardi M, Ortega-Paz L, Nerla R, D'Amario D, Franchi F, Biondi-Zoccai G, Angiolillo DJ. Bivalirudin in acute coronary syndromes. Expert Rev Cardiovasc Ther 2023; 21:901-911. [PMID: 37919937 DOI: 10.1080/14779072.2023.2273902] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Bivalirudin, a bivalent direct thrombin inhibitor, has been developed to reduce bleeding without any trade-off in thrombotic events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). AREAS COVERED Despite showing a superior safety profile compared with unfractionated heparin (UFH), bivalirudin is not considered the anticoagulant of choice in ACS patients undergoing PCI, mainly because of an increased rate of acute stent thrombosis (ST) shown by several randomized controlled trials (RCTs), in addition to limited availability in certain countries and increased costs. However, RCTs on bivalirudin have been characterized by several confounding factors hindering the interpretation of its safety and efficacy compared with UFH among the spectrum of ACS patients. Furthermore, a significant body of evidence has demonstrated that the risk of acute ST can be mitigated by a full-dose infusion regimen following PCI, without compromising the favorable safety profile compared to UFH. EXPERT OPINION In light of the increased understanding of the prognostic relevance of bleeding events and the excellent safety profile of bivalirudin, recent trial evidence may allow for this anticoagulant agent to reemerge and have a more prominent role in the management of ACS patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Marco Bernardi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roberto Nerla
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Domenico D'Amario
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Napoli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Abubakar M, Javed I, Rasool HF, Raza S, Basavaraju D, Abdullah RM, Ahmed F, Salim SS, Faraz MA, Hassan KM, Hajjaj M. Advancements in Percutaneous Coronary Intervention Techniques: A Comprehensive Literature Review of Mixed Studies and Practice Guidelines. Cureus 2023; 15:e41311. [PMID: 37539426 PMCID: PMC10395399 DOI: 10.7759/cureus.41311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
Percutaneous coronary intervention (PCI) is a widely used therapy for coronary artery disease (CAD), but it carries risks and complications. Adhering to evidence-based practice guidelines is crucial for optimal outcomes. This review compares the recommendations of the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) and 2018 European Society of Cardiology (ESC) guidelines for coronary artery revascularization and discusses emerging trends and novel devices in PCI. A comprehensive literature review of mixed studies, clinical trials, and guidelines was conducted. Intravascular imaging, including intravascular ultrasound and optical coherence tomography, for stent optimization, is also recommended when feasible. However, differences reflecting variations in evidence quality interpretation and applicability were identified. Furthermore, novel devices and technologies with the potential for improving outcomes were highlighted, but their safety and efficacy compared to standard-of-care techniques require further evaluation through extensive randomized trials. Clinicians should stay updated on advancements and personalize treatment decisions based on individual patient factors. Future research should address evidence gaps and barriers to adopting innovative devices and techniques. This review provides recommendations for clinical practice, emphasizing the need to remain current with the evolving landscape of PCI to optimize patient outcomes. The discoveries provide valuable counsel for the deliberation of clinical interventions and prospective inquiries within the realm of interventional cardiology. Overall, the review underscores the importance of evidence-based practice and ongoing advancements in PCI for CAD management.
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Affiliation(s)
- Muhammad Abubakar
- Department of Internal Medicine, Ameer-ud-Din Medical College/Lahore General Hospital, Lahore, PAK
- Department of Internal Medicine, Siddique Sadiq Memorial Trust Hospital, Gujranwala, PAK
| | - Izzah Javed
- Department of Internal Medicine, Ameer-ud-Din Medical College/Lahore General Hospital, Lahore, PAK
| | - Hafiz Fahad Rasool
- Department of Public Health, School of Public Health, Nanjing Medical University, Nanjing, CHN
| | - Saud Raza
- Department of Internal Medicine, Ameer-ud-Din Medical College/Lahore General Hospital, Lahore, PAK
| | - Deepak Basavaraju
- Department of Internal Medicine, Mysore Medical College and Research Institute, Mysore, IND
| | | | - Faizan Ahmed
- Department of Internal Medicine, Ameer-ud-Din Medical College/Lahore General Hospital, Lahore, PAK
| | - Siffat S Salim
- Department of Surgery, Holy Family Red Crescent Medical College Hospital, Dhaka, BGD
| | - Muhammad Ahmad Faraz
- Department of Forensic Medicine, Post Graduate Medical Institute, Lahore General Hospital, Lahore, PAK
| | - Khawaja Mushammar Hassan
- Department of Internal Medicine, Ameer-ud-Din Medical College/Lahore General Hospital, Lahore, PAK
| | - Mohsin Hajjaj
- Department of Internal Medicine, Jinnah Hospital, Lahore, PAK
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11
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Sabouret P, Spadafora L, Fischman D, Ullah W, Zeitouni M, Gulati M, De Rosa S, Savage MP, Costabel JP, Banach M, Biondi-Zoccai G, Galli M. De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy? Eur J Intern Med 2023; 110:1-9. [PMID: 36575107 DOI: 10.1016/j.ejim.2022.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y12 inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y12 inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.
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Affiliation(s)
- Pierre Sabouret
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France; Collège National des Cardiologues Français (CNCF), Paris, France.
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - David Fischman
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Waqas Ullah
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Michel Zeitouni
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, USA
| | | | | | - Juan Pablo Costabel
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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12
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Acetylsalicylic acid challenge or desensitization in sensitive patients with cardiovascular disease. J Thromb Thrombolysis 2023; 55:762-769. [PMID: 36757645 DOI: 10.1007/s11239-023-02782-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/10/2023]
Abstract
The use of acetylsalicylic acid (ASA) is problematic in subjects with histories of hypersensitivity reactions (HRs) to it or with cross-reactive types of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. We sought to evaluate the efficacy of low-dose ASA challenge (LDAC) and desensitization to allow ASA therapy at an antiplatelet dose in patients with atherosclerotic cardiovascular disease (ASCVD) or multiple related risk factors and histories of HRs to ASA or ≥ 2 chemically unrelated NSAIDs. We studied prospectively all patients with such histories and ≥ 3 risk factors for ASCVD (group I), chronic coronary syndrome (CCS, group II), and acute coronary syndrome (ACS) with indication for ASA desensitization (group III). Patients from groups I and II underwent LDACs (cumulative dose of 110 mg), while those from group III were desensitized (cumulative dose of 100.1 mg). We evaluated 103 patients: 62 from group I, 24 from group II, and 17 from group III. Eighty-two of the 86 patients from the first two groups underwent LDACs and 2 reacted. Subsequently, 22 (27.5%) of the 80 patients with negative LDACs were administered dual antiplatelet therapy with ASA after successful percutaneous coronary interventions, thus sparing desensitizations. The remaining 4 patients with CCS and all 17 patients from group III were successfully desensitized. In this pragmatic study, LDAC proved to be a safe and reliable diagnostic tool for identifying patients with histories of HRs to ASA or ≥ 2 different NSAIDs who can tolerate ASA at antiplatelet doses. Routine LDAC is advisable in all patients at high risk for ASCVD or with CCS who report HRs to ASA or ≥ 2 NSAIDs. ASA desensitization remains a safe and effective option in patients with ACS. Study flow-chart. ASCVD atherosclerotic cardiovascular disease; CCS chronic coronary syndrome; ACS acute coronary syndrome; ASA acetylsalicylic acid; DAPT dual antiplatelet therapy; PCI percutaneous coronary intervention; NSAIDs nonsteroidal anti-inflammatory drugs; NERD NSAID-exacerbated respiratory disease; NECD NSAID-exacerbated cutaneous disease; NIUAA NSAID-induced urticaria-angioedema or anaphylaxis; SNIUAA single NSAID-induced urticaria-angioedema or anaphylaxis; SNIDHR single NSAID-induced delayed hypersensitivity reaction.
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13
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Galli M, Costa F, Angiolillo DJ. Editorial: Precision medicine for antithrombotic therapy in patients after percutaneous coronary interventions. Front Cardiovasc Med 2023; 10:1162630. [PMID: 36937928 PMCID: PMC10020611 DOI: 10.3389/fcvm.2023.1162630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Mattia Galli
- Department of Cardiology, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
- Correspondence: Mattia Galli
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
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14
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Laborante R, Borovac JA, Galli M, Rodolico D, Ciliberti G, Restivo A, Cappannoli L, Arcudi A, Vergallo R, Zito A, Princi G, Leone AM, Aurigemma C, Romagnoli E, Montone RA, Burzotta F, Trani C, D’Amario D. Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome? Front Cardiovasc Med 2022; 9:1009475. [PMID: 36386309 PMCID: PMC9659635 DOI: 10.3389/fcvm.2022.1009475] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/14/2022] [Indexed: 08/11/2023] Open
Abstract
The incidence and clinical presentation of ischemic heart disease (IHD), as well as thrombotic and bleeding risks, appear to differ between genders. Compared with men, women feature an increased thrombotic risk, probably related to an increased platelet reactivity, higher level of coagulation factors, and sex-associated unique cardiovascular risk factors, such as pregnancy-related (i.e., pre-eclampsia and gestational diabetes), gynecological disorders (i.e., polycystic ovary syndrome, early menopause) and autoimmune or systemic inflammatory diseases. At the same time, women are also at increased risk of bleeding, due to inappropriate dosing of antithrombotic agents, smaller blood vessels, lower body weight and comorbidities, such as diabetes and chronic kidney disease. Pharmacological strategies focused on the personalization of antithrombotic treatment may, therefore, be particularly appealing in women in light of their higher bleeding and ischemic risks. Paradoxically, although women represent a large proportion of cardiovascular patients in our practice, adequate high-quality clinical trial data on women remain scarce and inadequate to guide decision-making processes. As a result, IHD in women tends to be understudied, underdiagnosed and undertreated, a phenomenon known as a "Yentl syndrome." It is, therefore, compelling for the scientific community to embark on dedicated clinical trials to address underrepresentation of women and to acquire evidence-based knowledge in the personalization of antithrombotic therapy in women.
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Affiliation(s)
- Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Josip Andjelo Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Cappannoli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Arcudi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Zito
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D’Amario
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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15
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Mazzone PM, Angiolillo DJ, Capodanno D. Approaches to de-escalation of antiplatelet treatment in stabilized post-myocardial infarction patients with high ischemic risk. Expert Rev Cardiovasc Ther 2022; 20:839-849. [DOI: 10.1080/14779072.2022.2137492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
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16
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Spadafora L, Bernardi M, Galli M, Biondi-Zoccai G, Sabouret P. Which future for aspirin in acute coronary syndromes treated with percutaneous coronary intervention? An overview on aspirin-free strategies. Arch Med Sci 2022; 18:1689-1692. [PMID: 36457983 PMCID: PMC9710287 DOI: 10.5114/aoms/155411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/14/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Pierre Sabouret
- Heart Institute, 47-83 Boulevard de l’Hôpital, ACTION Study Group-CHU Pitié-Salpétrière Paris, Paris, France
- Collège National des Cardiologues Français (CNCF), Paris, France
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