1
|
Lee YJ, Shin S, Kwon SW, Suh Y, Yun KH, Kang TS, Lee JW, Cho DK, Park JK, Bae JW, Kang WC, Kim S, Lee SJ, Hong SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK. Ticagrelor monotherapy for acute coronary syndrome: an individual patient data meta-analysis of TICO and T-PASS trials. Eur Heart J 2024; 45:3045-3056. [PMID: 38750627 DOI: 10.1093/eurheartj/ehae249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/22/2024] [Accepted: 04/08/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND AND AIMS In patients with acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 inhibitor is recommended for 12 months after drug-eluting stent (DES) implantation. Monotherapy with a potent P2Y12 inhibitor after short-term DAPT is an attractive option to better balance the risks of ischaemia and bleeding. Therefore, this study evaluated the efficacy and safety of ticagrelor monotherapy after short-term DAPT, especially in patients with ACS. METHODS Electronic databases were searched from inception to 11 November 2023, and for the primary analysis, individual patient data were pooled from the relevant randomized clinical trials comparing ticagrelor monotherapy after short-term (≤3 months) DAPT with ticagrelor-based 12-month DAPT, exclusively in ACS patients undergoing DES implantation. The co-primary endpoints were ischaemic endpoint (composite of all-cause death, myocardial infarction, or stroke) and bleeding endpoint [Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding] at 1 year. RESULTS Individual patient data from two randomized clinical trials including 5906 ACS patients were analysed. At 1 year, the primary ischaemic endpoint did not differ between the ticagrelor monotherapy and ticagrelor-based DAPT groups [1.9% vs. 2.5%; adjusted hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.56-1.13; P = .194]. The incidence of the primary bleeding endpoint was lower in the ticagrelor monotherapy group (2.4% vs. 4.5%; adjusted HR 0.54; 95% CI 0.40-0.72; P < .001). The results were consistent in a secondary aggregate data meta-analysis including the ACS subgroup of additional randomized clinical trials which enrolled patients with ACS as well as chronic coronary syndrome. CONCLUSIONS In ACS patients undergoing DES implantation, ticagrelor monotherapy after short-term DAPT was associated with less major bleeding without a concomitant increase in ischaemic events compared with ticagrelor-based 12-month DAPT. STUDY REGISTRATION PROSPERO (ID: CRD42023476470).
Collapse
Affiliation(s)
- Yong-Joon Lee
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Sanghoon Shin
- Department of Cardiology, Ewha Womans University College of Medicine Seoul Hospital, Seoul, Korea
| | - Sung Woo Kwon
- Department of Cardiology, Inha University Hospital, Incheon, Korea
| | - Yongsung Suh
- Myongji Hospital, Hanyang University College of Medicine, 55 Hwasu-ro 14 beon-gil, Deokyang-gu, 10475 Goyang, Korea
| | - Kyeong Ho Yun
- Department of Cardiology, Wonkwang University Hospital, Iksan, Korea
| | - Tae Soo Kang
- Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Jun-Won Lee
- Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Deok-Kyu Cho
- Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jong-Kwan Park
- Department of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jang-Whan Bae
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Woong Cheol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Seunghwan Kim
- Department of Cardiology, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Seung-Jun Lee
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Sung-Jin Hong
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Chul-Min Ahn
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Jung-Sun Kim
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Byeong-Keuk Kim
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Young-Guk Ko
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Donghoon Choi
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA University College of Medicine, Seongnam, Korea
| | - Myeong-Ki Hong
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| |
Collapse
|
2
|
Yu S, Guo L, Guo H. Aspirin-free P2Y12 inhibitor monotherapy immediately after percutaneous coronary intervention: A systematic review. Heliyon 2024; 10:e35741. [PMID: 39170240 PMCID: PMC11336810 DOI: 10.1016/j.heliyon.2024.e35741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/26/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024] Open
Abstract
Background A modified antiplatelet therapy approach after percutaneous coronary intervention (PCI), specifically reducing dual antiplatelet therapy (DAPT) duration and transitioning to P2Y12 inhibitor monotherapy, may offer advantages in terms of bleeding risk reduction. However, the impact of initiating aspirin-free P2Y12 inhibitor monotherapy immediately after PCI is not yet fully understood. Methods We systematically searched the PubMed and Embase databases until January 2024 for studies that examined the use of P2Y12 inhibitor monotherapy as a treatment approach without initial DAPT following PCI. Results Four single-arm pilot prospective studies and 1 randomized controlled trial were included. In acute coronary syndrome patients with P2Y12 monotherapy following aspirin withdrawal immediately after PCI, the occurrence rates of the primary ischemic and bleeding endpoint were 2.91 % (8 out of 275 patients) and 1.09 % (3 out of 275 patients) respectively, whereas both the incidence rates of the primary ischemic and bleeding endpoints were 0.25 % (1 out of 407 patients) in individuals with stable coronary artery disease. In the STOPDAPT-3 trial comparing the effect of aspirin-free prasugrel monotherapy with standard DAPT after PCI, no differences were found in the primary ischemic or bleeding endpoints and most secondary outcomes (death, stroke, and myocardial infarction). However, there was an increased risk of coronary revascularization and stent thrombosis in the no-aspirin group. Conclusions Single-arm studies suggest the safety and feasibility of aspirin-free P2Y12 inhibitor monotherapy without initial DAPT after PCI in selected patients with acute coronary syndrome or stable coronary artery disease. However, the safety and efficacy of this aspirin-free approach compared with standard DAPT strategies following PCI still require further investigation.
Collapse
Affiliation(s)
- Shenglong Yu
- Department of Cardiovascular, the Affiliated Panyu Central Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Huizhuang Guo
- Department of Radiology, the Affiliated Panyu Central Hospital of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
3
|
Obayashi Y, Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Nishikawa R, Ando K, Suwa S, Isawa T, Takenaka H, Ishikawa T, Tokuyama H, Sakamoto H, Fujita T, Nanasato M, Okayama H, Nishikura T, Kirigaya H, Nishida K, Ono K, Kimura T. Aspirin-free strategy for percutaneous coronary intervention in acute coronary syndrome based on the subtypes of acute coronary syndrome and high bleeding risk: the STOPDAPT-3 trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:374-390. [PMID: 38285607 DOI: 10.1093/ehjcvp/pvae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 12/23/2023] [Accepted: 01/25/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND AND AIMS High bleeding risk (HBR) and acute coronary syndrome (ACS) subtypes are critical in determining bleeding and cardiovascular event risk after percutaneous coronary intervention (PCI). METHODS AND RESULTS In 4476 ACS patients enrolled in the STOPDAPT-3, where the no-aspirin and dual antiplatelet therapy (DAPT) strategies after PCI were randomly compared, the pre-specified subgroup analyses were conducted based on HBR/non-HBR and ST-segment elevation myocardial infarction (STEMI)/non-ST-segment elevation ACS (NSTE-ACS). The co-primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5, and the co-primary cardiovascular endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischaemic stroke at 1 month. Irrespective of the subgroups, the effect of no-aspirin compared with DAPT was not significant for the bleeding endpoint (HBR [N = 1803]: 7.27 and 7.91%, hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.65-1.28; non-HBR [N = 2673]: 3.40 and 3.65%, HR 0.93, 95% CI 0.62-1.39; Pinteraction = 0.94; STEMI [N = 2553]: 6.58 and 6.56%, HR 1.00, 95% CI 0.74-1.35; NSTE-ACS [N = 1923]: 2.94 and 3.64%, HR 0.80, 95% CI 0.49-1.32; Pinteraction = 0.45), and for the cardiovascular endpoint (HBR: 7.87 and 5.75%, HR 1.39, 95% CI 0.97-1.99; non-HBR: 2.56 and 2.67%, HR 0.96, 95% CI 0.60-1.53; Pinteraction = 0.22; STEMI: 6.07 and 5.46%, HR 1.11, 95% CI 0.81-1.54; NSTE-ACS: 3.03 and 1.71%, HR 1.78, 95% CI 0.97-3.27; Pinteraction = 0.18). CONCLUSION In patients with ACS undergoing PCI, the no-aspirin strategy compared with the DAPT strategy failed to reduce major bleeding events irrespective of HBR and ACS subtypes. The numerical excess risk of the no-aspirin strategy relative to the DAPT strategy for cardiovascular events was observed in patients with HBR and in patients with NSTE-ACS.
Collapse
Affiliation(s)
- Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Masahiro Natsuaki
- Department of Cardiovascular Medicine, Saga University, Saga 849-8501, Japan
| | - Hirotoshi Watanabe
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata 573-0153, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya 663-8501, Japan
| | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu 802-8555, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu 802-8555, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni 410-2295, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai 980-0873, Japan
| | - Hiroyuki Takenaka
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata 573-0153, Japan
| | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya 343-8555, Japan
| | - Hideo Tokuyama
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi 333-0842, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka 420-8527, Japan
| | - Takanari Fujita
- Division of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama 640-8558, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Fuchu 183-0003, Japan
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama 790-0024, Japan
| | - Tenjin Nishikura
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo 135-8577, Japan
| | - Hidekuni Kirigaya
- Division of Cardiology, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Koji Nishida
- Division of Cardiology, Chikamori Hospital, Kochi 780-8522, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata 573-0153, Japan
| |
Collapse
|
4
|
Singh S, Garg A, Tantry US, Bliden K, Abbott JD, Gurbel PA. P2Y12 Inhibitor Monotherapy After Short-Term Dual Antiplatelet Therapy in Acute Coronary Syndrome. Am J Cardiol 2024; 224:1-8. [PMID: 38734399 DOI: 10.1016/j.amjcard.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/20/2024] [Accepted: 05/05/2024] [Indexed: 05/13/2024]
Abstract
Recent studies have shown similar safety and efficacy of short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor (P2Y12i) monotherapy when compared with standard DAPT. However, the optimal DAPT duration and regimen in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention is still unclear. Online databases were searched for randomized controlled trials evaluating P2Y12i monotherapy after short DAPT (≤3 months) versus standard DAPT (≥12 months) in ACS patients. The outcomes of interest were all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, target-vessel revascularization, and major bleeding. Random-effects model was used to calculate pooled odds ratios (OR) and 95% confidence intervals (CI). Six randomized controlled trials with a total of 23,884 patients (n = 11,904 P2Y12i monotherapy, n = 11,980 standard DAPT) were included. Compared with standard DAPT, P2Y12i monotherapy after short DAPT was associated with similar odds of all-cause death (OR 0.86, 95% CI 0.65 to 1.12, p = 0.26) and cardiovascular death (OR 0.75, 95% CI 0.43 to 1.29, p = 0.29) at 1 year. Similarly, there were no significant differences in rates of myocardial infarction (OR 1.09, 0.83 to 1.43, p = 0.53), stent thrombosis (OR 1.09, 95% CI 0.71 to 1.67, p = 0.70) and target-vessel revascularization (OR 0.81, 95% CI 0.65 to 1.01, p = 0.07) between the P2Y12i monotherapy and standard DAPT arms. The P2Y12i monotherapy group had significantly lower major bleeding (OR 0.49, 95% CI 0.38 to 0.64, p < 0.001) when compared with standard DAPT. In conclusion, in patients with ACS who underwent percutaneous coronary intervention, P2Y12i monotherapy after short DAPT significantly reduces bleeding without increasing ischemic risk when compared with standard DAPT therapy.
Collapse
Affiliation(s)
- Sahib Singh
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Aakash Garg
- Division of Cardiology, Ellis Hospital, New York.
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Kevin Bliden
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - J Dawn Abbott
- Division of Cardiology, Brown University, Providence, Rhode Island
| | - Paul A Gurbel
- Division of Cardiology, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
5
|
Cao D, Vranckx P, Valgimigli M, Sartori S, Angiolillo DJ, Bangalore S, Bhatt DL, Feng Y, Ge J, Hermiller J, Makkar RR, Neumann FJ, Saito S, Picon H, Toelg R, Maksoud A, Chehab BM, Choi JW, Campo G, De la Torre Hernandez JM, Krucoff MW, Kunadian V, Sardella G, Spirito A, Thiele H, Varenne O, Vogel B, Zhou Y, Windecker S, Mehran R. One- versus three-month dual antiplatelet therapy in high bleeding risk patients undergoing percutaneous coronary intervention for non-ST-segment elevation acute coronary syndromes. EUROINTERVENTION 2024; 20:e630-e642. [PMID: 38776146 PMCID: PMC11100501 DOI: 10.4244/eij-d-23-00658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/12/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND A short dual antiplatelet therapy (DAPT) duration has been proposed for patients at high bleeding risk (HBR) undergoing drug-eluting coronary stent (DES) implantation. Whether this strategy is safe and effective after a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. AIMS We aimed to compare the impact of 1-month versus 3-month DAPT on clinical outcomes after DES implantation among HBR patients with or without NSTE-ACS. METHODS This is a prespecified analysis from the XIENCE Short DAPT programme involving three prospective, international, single-arm studies evaluating the safety and efficacy of 1-month (XIENCE 28 USA and Global) or 3-month (XIENCE 90) DAPT among HBR patients after implantation of a cobalt-chromium everolimus-eluting stent. Ischaemic and bleeding outcomes associated with 1- versus 3-month DAPT were assessed according to clinical presentation using propensity score stratification. RESULTS Of 3,364 HBR patients (1,392 on 1-month DAPT and 1,972 on 3-month DAPT), 1,164 (34.6%) underwent DES implantation for NSTE-ACS. At 12 months, the risk of the primary endpoint of death or myocardial infarction was similar between 1- and 3-month DAPT in patients with (hazard ratio [HR] 1.09, 95% confidence interval [CI]: 0.71-1.65) and without NSTE-ACS (HR 0.88, 95% CI: 0.63-1.23; p-interaction=0.34). The key secondary endpoint of Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding was consistently reduced in both NSTE-ACS (HR 0.57, 95% CI: 0.37-0.88) and stable patients (HR 0.84, 95% CI: 0.61-1.15; p-interaction=0.15) with 1-month DAPT. CONCLUSIONS Among HBR patients undergoing implantation of an everolimus-eluting stent, 1-month, compared to 3-month DAPT, was associated with similar ischaemic risk and reduced bleeding at 1 year, irrespective of clinical presentation.
Collapse
Affiliation(s)
- Davide Cao
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Pascal Vranckx
- Heart Centre Hasselt, Hasselt, Belgium and University of Hasselt, Hasselt, Belgium
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Bern University Hospital, Bern, Switzerland
| | - Samantha Sartori
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yihan Feng
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Junbo Ge
- Zhongshan Hospital Fudan University, Shanghai, China
| | - James Hermiller
- St Vincent's Medical Center of Indiana, Indianapolis, IN, USA
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | - Ralph Toelg
- Segeberger Kliniken GmbH, Herzzentrum, Bad Segeberg, Germany
| | - Aziz Maksoud
- Kansas Heart Hospital, Wichita, KS, USA and University of Kansas School of Medicine, Wichita, KS, USA
| | | | - James W Choi
- Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | - Gianluca Campo
- Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | | | - Mitchell W Krucoff
- Duke University Medical Center, Durham, NC, USA and Duke Clinical Research Institute, Durham, NC, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Alessandro Spirito
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany and Leipzig Heart Institute, Leipzig, Germany
| | | | - Birgit Vogel
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
6
|
Lee SY, Cho JY, Gorog DA, Angiolillo DJ, Yun KH, Ahn JH, Koh JS, Park Y, Hwang SJ, Hwang JY, Kim JW, Jang Y, Jeong YH. Inflammation and platelet reactivity during adjunctive colchicine versus aspirin in patients with acute coronary syndrome treated with potent P2Y12 inhibitor. Front Med (Lausanne) 2024; 11:1349577. [PMID: 38841588 PMCID: PMC11151890 DOI: 10.3389/fmed.2024.1349577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/28/2024] [Indexed: 06/07/2024] Open
Abstract
Background In patients undergoing percutaneous coronary intervention (PCI), the use of anti-inflammatory therapy with colchicine is associated with a reduction of recurrent ischemic events. The mechanisms of such findings are not fully elucidated. Objectives To investigate the effects of colchicine versus aspirin on inflammation and platelet reactivity in patients with acute coronary syndrome (ACS) undergoing PCI. Methods This observational study compared laboratory measurements in ACS patients receiving single antiplatelet therapy with ticagrelor or prasugrel plus colchicine (MACT) (n = 185) versus conventional dual-antiplatelet therapy (DAPT) with aspirin plus ticagrelor or prasugrel (n = 497). The primary outcome was the frequency of high residual inflammation, defined as high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L at 1 month post-PCI. Multiple sensitivity analyses were performed for the primary outcome, including multivariable adjustment, propensity-score matching, and inverse-probability weighted methods. Results One month after PCI, patients treated with MACT had significantly lower levels of hs-CRP compared to those treated with DAPT (0.6 [0.4-1.2] vs. 0.9 [0.6-2.3] mg/L, p < 0.001). The frequency of high residual inflammation was also lower in the MACT group (10.8% vs. 27.2%, p < 0.001) (odds ratio [95% confidence interval] = 0.33 [0.20-0.54], p < 0.001). This effect was consistent across sensitivity analyses. There was no difference in platelet reactivity between MACT and DAPT (49.6 ± 49.0 vs. 51.5 ± 66.4 P2Y12 reaction unit [PRU] measured by VerifyNow, p = 0.776). Conclusion In ACS patients undergoing PCI, MACT was associated with a lower rate of high residual inflammation without increasing platelet reactivity compared to conventional DAPT. Clinical trial registration NCT04949516 for MACT pilot trial and NCT04650529 for Gyeongsang National University Hospital registry.
Collapse
Affiliation(s)
- Seung-Yul Lee
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Republic of Korea
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jae Young Cho
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Diana A. Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Kyeong Ho Yun
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Division of Cardiology, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Division of Cardiology, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Division of Cardiology, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin Won Kim
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Yangsoo Jang
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
7
|
Masuda S, Tanabe K, Guimarães PO, Muramatsu T, Ozaki Y, De Martino F, Kozuma K, Garg S, Kotoku N, Ninomiya K, Kageyama S, Lemos PA, Onuma Y, Serruys PW. Prasugrel Monotherapy After Percutaneous Coronary Intervention for Chronic Coronary Syndrome: Insights From ASET Pilot Studies. JACC. ASIA 2024; 4:171-182. [PMID: 38463674 PMCID: PMC10920039 DOI: 10.1016/j.jacasi.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 03/12/2024]
Abstract
Background The ASET (Acetyl-Salicylic Elimination Trial) pilot studies recently investigated P2Y12 inhibitor monotherapy without aspirin immediately after percutaneous coronary intervention (PCI) in Brazil and Japan. Objectives This comparative analysis of the 2 ASET pilot studies aimed to summarize clinical outcomes and assess geographic and ethnic differences in baseline demographics and procedures. Methods Patients undergoing successful platinum-chromium everolimus-eluting stent implantation for chronic coronary syndrome were included. Following the index PCI, patients received prasugrel monotherapy with a maintenance dose of 10 mg/day in Brazil and 3.75 mg/day in Japan. The primary ischemic endpoint was the composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis. The primary bleeding endpoint was Bleeding Academic Research Consortium types 3 and 5 bleeding at up to 3 months. Results Of 409 enrollments, 3-month follow-up was completed in 406 patients. Mean age was 64.3 ± 8.4 years, and 73% were men. Overall, post-TIMI flow grade 3 was achieved in 99.8%. Intravascular imaging for poststent optimization was used in 16.8% and 99.6% of treated lesions in Brazil and Japan, respectively. The primary ischemic and bleeding endpoints occurred in the same patient (0.2%). No stent thrombosis events occurred. Conclusions Prasugrel monotherapy following PCI was safe and feasible in selected low-risk chronic coronary syndrome patients after optimal platinum-chromium everolimus-eluting stent implantation regardless of the ethnic and geographic differences in baseline demographics, procedures, and prasugrel dosage. Randomized controlled trials will be needed to compare P2Y12 inhibitor monotherapy without aspirin with the current standard of care.
Collapse
Affiliation(s)
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Patricia O. Guimarães
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University Hospital, Toyoake, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Fernando De Martino
- Department of Internal Medicine, Discipline of Cardiology, University of Triangulo Mineiro, Uberaba, Brazil
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
- Department of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Nozomi Kotoku
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Pedro A. Lemos
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
| | | |
Collapse
|
8
|
Capranzano P, Moliterno D, Capodanno D. Aspirin-free antiplatelet strategies after percutaneous coronary interventions. Eur Heart J 2024; 45:572-585. [PMID: 38240716 DOI: 10.1093/eurheartj/ehad876] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/20/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a platelet P2Y12 receptor inhibitor is the standard antithrombotic treatment after percutaneous coronary interventions (PCI). Several trials have challenged guideline-recommended DAPT after PCI by testing the relative clinical effect of an aspirin-free antiplatelet approach-consisting of P2Y12 inhibitor monotherapy after a short course (mostly 1-3 months) of DAPT-among patients undergoing PCI without a concomitant indication for oral anticoagulation (OAC). Overall, these studies have shown P2Y12 inhibitor monotherapy after short DAPT to be associated with a significant reduction in the risk of bleeding without an increase in thrombotic or ischaemic events compared with continued DAPT. Moreover, the effects of the P2Y12 inhibitor monotherapy without prior DAPT or following a very short course of DAPT after PCI are being investigated in emerging studies, of which one has recently reported unfavourable efficacy results associated with the aspirin-free approach compared with conventional DAPT. Finally, P2Y12 inhibitor alone has been compared with aspirin alone as chronic therapy after DAPT discontinuation, thus challenging the historical role of aspirin as a standard of care for secondary prevention following PCI. A thorough understanding of study designs, populations, treatments, results, and limitations of trials testing P2Y12 inhibitor monotherapy vs. DAPT or vs. aspirin is required to consider adopting this treatment in clinical practice. This review addresses the use of aspirin-free antiplatelet strategies among patients undergoing PCI without a concomitant indication for OAC, providing an overview of clinical evidence, guideline indications, practical implications, ongoing issues, and future perspectives.
Collapse
Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
| | - David Moliterno
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, The University of Kentucky, Lexington, KY, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
| |
Collapse
|
9
|
Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Domei T, Suwa S, Ogita M, Isawa T, Takenaka H, Yamamoto T, Ishikawa T, Hisauchi I, Wakabayashi K, Onishi Y, Hibi K, Kawai K, Yoshida R, Suzuki H, Nakazawa G, Kusuyama T, Morishima I, Ono K, Kimura T. An Aspirin-Free Versus Dual Antiplatelet Strategy for Coronary Stenting: STOPDAPT-3 Randomized Trial. Circulation 2024; 149:585-600. [PMID: 37994553 DOI: 10.1161/circulationaha.123.066720] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Bleeding rates on dual antiplatelet therapy (DAPT) within 1 month after percutaneous coronary intervention (PCI) remain high in clinical practice, particularly in patients with acute coronary syndrome or high bleeding risk. Aspirin-free strategy might result in lower bleeding early after PCI without increasing cardiovascular events, but its efficacy and safety have not yet been proven in randomized trials. METHODS We randomly assigned 6002 patients with acute coronary syndrome or high bleeding risk just before PCI either to prasugrel (3.75 mg/day) monotherapy or to DAPT with aspirin (81-100 mg/day) and prasugrel (3.75 mg/day) after loading of 20 mg of prasugrel in both groups. The coprimary end points were major bleeding (Bleeding Academic Research Consortium 3 or 5) for superiority and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke) for noninferiority with a relative 50% margin. RESULTS The full analysis set population consisted of 5966 patients (no-aspirin group, 2984 patients; DAPT group, 2982 patients; age, 71.6±11.7 years; men, 76.6%; acute coronary syndrome, 75.0%). Within 7 days before randomization, aspirin alone, aspirin with P2Y12 inhibitor, oral anticoagulants, and intravenous heparin infusion were given in 21.3%, 6.4%, 8.9%, and 24.5%, respectively. Adherence to the protocol-specified antiplatelet therapy was 88% in both groups at 1 month. At 1 month, the no-aspirin group was not superior to the DAPT group for the coprimary bleeding end point (4.47% and 4.71%; hazard ratio, 0.95 [95% CI, 0.75-1.20]; Psuperiority=0.66). The no-aspirin group was noninferior to the DAPT group for the coprimary cardiovascular end point (4.12% and 3.69%; hazard ratio, 1.12 [95% CI, 0.87-1.45]; Pnoninferiority=0.01). There was no difference in net adverse clinical outcomes and each component of coprimary cardiovascular end point. There was an excess of any unplanned coronary revascularization (1.05% and 0.57%; hazard ratio, 1.83 [95%CI, 1.01-3.30]) and subacute definite or probable stent thrombosis (0.58% and 0.17%; hazard ratio, 3.40 [95% CI, 1.26-9.23]) in the no-aspirin group compared with the DAPT group. CONCLUSIONS The aspirin-free strategy using low-dose prasugrel compared with the DAPT strategy failed to attest superiority for major bleeding within 1 month after PCI but was noninferior for cardiovascular events within 1 month after PCI. However, the aspirin-free strategy was associated with a signal suggesting an excess of coronary events. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04609111.
Collapse
Affiliation(s)
- Masahiro Natsuaki
- Department of Cardiovascular Medicine, Saga University, Japan (M.N.)
| | - Hirotoshi Watanabe
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (T.M.)
| | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan (S.S., M.O.)
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan (S.S., M.O.)
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Japan (T. Isawa)
| | - Hiroyuki Takenaka
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Takashi Yamamoto
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan (T. Ishikawa, I.H.)
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan (T. Ishikawa, I.H.)
| | - Kohei Wakabayashi
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan (K.W.)
| | - Yuko Onishi
- Department of Cardiology, Hiratsuka Kyosai Hospital, Japan (Y. Onishi)
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Japan (K.H.)
| | - Kazuya Kawai
- Division of Cardiology, Chikamori Hospital, Kochi, Japan (K.K.)
| | - Ruka Yoshida
- Division of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan (R.Y.)
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan (H.S.)
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan (G.N.)
| | - Takanori Kusuyama
- Division of Cardiology, Tsukazaki Hospital, Himeji, Japan (T. Kusuvama)
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.)
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
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: 16] [Impact Index Per Article: 16.0] [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.
Collapse
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
| |
Collapse
|
12
|
Carciotto G, Costa F, Garcia-Ruiz V, Galli M, Soraci E, Magliarditi A, Teresi L, Nasso E, Carerj S, Di Bella G, Micari A, De Luca G. Individualization of Duration of Dual Antiplatelet Therapy after Coronary Stenting: A Comprehensive, Evidence-Based Review. J Clin Med 2023; 12:7144. [PMID: 38002756 PMCID: PMC10672070 DOI: 10.3390/jcm12227144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is the cornerstone of post-percutaneous coronary intervention treatment to prevent stent thrombosis and reduce the risk of adverse cardiovascular events. The selection of an optimal DAPT regimen, considering the interplay of various antiplatelet agents, patient profiles, and procedural characteristics, remains an evolving challenge. Traditionally, a standard duration of 12 months has been recommended for DAPT in most patients. While contemporary guidelines provide general frameworks, DAPT modulation with longer or shorter treatment courses followed by aspirin or P2Y12 inhibitor monotherapy are evolving towards an individualized strategy to optimize the balance between efficacy and safety. This review comprehensively examines the current landscape of DAPT strategies after coronary stenting, with a focus on emerging evidence for treatment individualization.
Collapse
Affiliation(s)
- Gabriele Carciotto
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Francesco Costa
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | | | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy;
| | - Emmanuele Soraci
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Alberto Magliarditi
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Lucio Teresi
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Enrica Nasso
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Antonio Micari
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | - Giuseppe De Luca
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
| |
Collapse
|
13
|
van der Sangen NMR, Küçük IT, Sivanesan S, Appelman Y, Ten Berg JM, Verburg A, Azzahhafi J, Arkenbout EK, Kikkert WJ, Pisters R, Jukema JW, Arslan F, van 't Hof A, Ilhan M, Hoebers LP, van der Schaaf RJ, Damman P, Woudstra P, van de Hoef TP, Bax M, Anthonio RL, Polad J, Adriaenssens T, Dewilde W, Zivelonghi C, Laanmets P, Majas R, Dijkgraaf MGW, Claessen BEPM, Henriques JPS. Less bleeding by omitting aspirin in non-ST-segment elevation acute coronary syndrome patients: Rationale and design of the LEGACY study. Am Heart J 2023; 265:114-120. [PMID: 37517430 DOI: 10.1016/j.ahj.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Early aspirin withdrawal, also known as P2Y12-inhibitor monotherapy, following percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) can reduce bleeding without a trade-off in efficacy. Still the average daily bleeding risk is highest during the first months and it remains unclear if aspirin can be omitted immediately following PCI. METHODS The LEGACY study is an open-label, multicenter randomized controlled trial evaluating the safety and efficacy of immediate P2Y12-inhibitor monotherapy versus dual antiplatelet therapy (DAPT) for 12 months in 3,090 patients. Patients are randomized immediately following successful PCI for NSTE-ACS to 75-100 mg aspirin once daily versus no aspirin. The primary hypothesis is that immediately omitting aspirin is superior to DAPT with respect to major or minor bleeding defined as Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, while maintaining noninferiority for the composite of all-cause mortality, myocardial infarction and stroke compared to DAPT. CONCLUSIONS The LEGACY study is the first randomized study that is specifically designed to evaluate the impact of immediately omitting aspirin, and thus treating patients with P2Y12-inhibitor monotherapy, as compared to DAPT for 12 months on bleeding and ischemic events within 12 months following PCI for NSTE-ACS.
Collapse
Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Shabiga Sivanesan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands
| | - Ashley Verburg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E Karin Arkenbout
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fatih Arslan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnoud van 't Hof
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mustafa Ilhan
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Loes P Hoebers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pier Woudstra
- Department of Cardiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Matthijs Bax
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Rutger L Anthonio
- Department of Cardiology, Treant Zorggroep, Scheper Hospital, Emmen, The Netherlands
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Ziekenhuis, Hertogenbosch, The Netherlands
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Willem Dewilde
- Department of Cardiology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Carlo Zivelonghi
- Department of Cardiology, HartCentrum, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Peep Laanmets
- Department of Cardiology, North Estonia Medical Center Foundation, Tallinn, Estonia
| | - Risko Majas
- Department of Cardiology, North Estonia Medical Center Foundation, Tallinn, Estonia
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| |
Collapse
|
14
|
van der Sangen NMR, Claessen BEPM, Küçük IT, den Hartog AW, Kikkert WJ, Appelman Y, Henriques JPS. One-year follow-up of patients treated with single antiplatelet therapy directly after percutaneous coronary intervention for non-ST-segment elevation acute coronary syndrome. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead075. [PMID: 37680589 PMCID: PMC10482140 DOI: 10.1093/ehjopen/oead075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/21/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023]
Abstract
Graphical AbstractClinical outcomes and treatment adherence during 12 months follow-up. *Second bleeding event in same patient. PCI, percutaneous coronary intervention; TVR, target vessel revascularization.
Collapse
Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Alexander W den Hartog
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Lee SY, Jeong YH, Yun KH, Cho JY, Gorog DA, Angiolillo DJ, Kim JW, Jang Y. P2Y 12 Inhibitor Monotherapy Combined With Colchicine Following PCI in ACS Patients: The MACT Pilot Study. JACC Cardiovasc Interv 2023; 16:1845-1855. [PMID: 37587591 DOI: 10.1016/j.jcin.2023.05.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND After a brief period of dual antiplatelet therapy, P2Y12 inhibitor monotherapy in the absence of aspirin effectively reduces bleeding without increasing recurrent ischemia in patients undergoing percutaneous coronary intervention (PCI). In addition, early anti-inflammatory therapies may have clinical benefits in acute coronary syndrome (ACS) patients. OBJECTIVES The aim of this study was to investigate the feasibility of ticagrelor or prasugrel P2Y12 inhibitor monotherapy combined with colchicine immediately after PCI in patients with ACS. METHODS This was a proof-of-concept pilot trial. ACS patients treated with drug-eluting stents were included. On the day after PCI, low-dose colchicine (0.6 mg daily) was administered in addition to ticagrelor or prasugrel maintenance therapy, whereas aspirin therapy was discontinued. The primary outcome was any stent thrombosis at 3 months. The key secondary outcomes were platelet reactivity measured by the VerifyNow assay (Accriva) before discharge and a reduction in high-sensitivity C-reactive protein (hs-CRP) over 1 month. RESULTS We enrolled 200 patients, 190 (95.0%) of whom completed the 3-month follow-up. The primary outcome occurred in 2 patients (1.0%): 1 definite and 1 probable stent thrombosis. The level of platelet reactivity overall was 27 ± 42 P2Y12 reaction units, and only 1 patient had high platelet reactivity (>208 P2Y12 reaction units). The hs-CRP levels decreased from 6.1 mg/L (IQR: 2.6-15.9 mg/L) at 24 hours after PCI to 0.6 mg/L (IQR: 0.4-1.2 mg/L) at 1 month (P < 0.001), and the prevalence of high-inflammation criteria (hs-CRP ≥2 mg/L) decreased from 81.8% to 11.8% (P < 0.001). CONCLUSIONS In ACS patients undergoing PCI, it is feasible to discontinue aspirin therapy and administer low-dose colchicine on the day after PCI in addition to ticagrelor or prasugrel P2Y12 inhibitors. This approach is associated with favorable platelet function and inflammatory profiles. (Mono Antiplatelet and Colchicine Therapy [MACT]; NCT04949516).
Collapse
Affiliation(s)
- Seung-Yul Lee
- CHA Bundang Medical Center, CHA University, Seongnam, Korea; Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea.
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyeong Ho Yun
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
| | - Jae Young Cho
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom; Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Jin Won Kim
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Yangsoo Jang
- CHA Bundang Medical Center, CHA University, Seongnam, Korea
| |
Collapse
|
16
|
Costa F, Micari A. Aspirin-Free Strategy After ACS Implementing Colchicine: Looking for a Substitution? JACC Cardiovasc Interv 2023; 16:1856-1859. [PMID: 37587592 DOI: 10.1016/j.jcin.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/26/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Francesco Costa
- Interventional Cardiology Unit, BIOMORF Department, University of Messina, Messina, Italy.
| | - Antonio Micari
- Interventional Cardiology Unit, BIOMORF Department, University of Messina, Messina, Italy
| |
Collapse
|
17
|
Guimarães PO, Franken M, Tavares CAM, Silveira FS, Antunes MO, Bergo RR, Joaquim RM, Hirai JCS, Andrade PB, Pitta FG, Mariani J, Nascimento BR, de Paula JET, Silveira MS, Costa TAO, Dall'Orto FTC, Serpa RG, Sampaio FBA, Ohe LN, Mangione FM, Furtado RHM, Sarmento-Leite R, Monfardini F, Assis SRL, Nicolau JC, Sposito AC, Lopes RD, Onuma Y, Valgimigli M, Angiolillo DJ, Serruys PW, Berwanger O, Bacal F, Lemos PA. P2Y12 inhibitor monotherapy versus dual antiplatelet therapy in patients with acute coronary syndromes undergoing coronary stenting: rationale and design of the NEOMINDSET Trial. EUROINTERVENTION 2023; 19:e323-e329. [PMID: 37306039 PMCID: PMC10333918 DOI: 10.4244/eij-d-23-00125] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/05/2023] [Indexed: 06/13/2023]
Abstract
Dual antiplatelet therapy (DAPT) is currently the standard of care after percutaneous coronary intervention (PCI). Recent studies suggest that reducing DAPT to 1-3 months followed by an aspirin-free single antiplatelet therapy (SAPT) strategy with a potent P2Y12 inhibitor is safe and associated with less bleeding. However, to date, no randomised trial has tested the impact of initiating SAPT immediately after PCI, particularly in patients with acute coronary syndromes (ACS). NEOMINDSET is a multicentre, randomised, open-label trial with a blinded outcome assessment designed to compare SAPT versus DAPT in 3,400 ACS patients undergoing PCI with the latest-generation drug-eluting stents (DES). After successful PCI and up to 4 days following hospital admission, patients are randomised to receive SAPT with a potent P2Y12 inhibitor (ticagrelor or prasugrel) or DAPT (aspirin plus a potent P2Y12 inhibitor) for 12 months. Aspirin is discontinued immediately after randomisation in the SAPT group. The choice between ticagrelor and prasugrel is at the investigator's discretion. The primary hypothesis is that SAPT will be non-inferior to DAPT with respect to the composite endpoint of all-cause mortality, stroke, myocardial infarction or urgent target vessel revascularisation, but superior to DAPT on rates of bleeding defined by Bleeding Academic Research Consortium 2, 3 or 5 criteria. NEOMINDSET is the first study that is specifically designed to test SAPT versus DAPT immediately following PCI with DES in ACS patients. This trial will provide important insights on the efficacy and safety of withdrawing aspirin in the early phase of ACS. (ClinicalTrials.gov: NCT04360720).
Collapse
Affiliation(s)
| | | | - Caio A M Tavares
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | | | - Murillo O Antunes
- Hospital Universitário São Francisco de Assis na Providência de Deus, Bragança Paulista, Brazil
| | | | | | | | - Pedro B Andrade
- Irmandade da Santa Casa de Misericórdia de Marilia, Marilia, Brazil
| | - Fabio G Pitta
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - José Mariani
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Tiberio A O Costa
- Hospital Universitário São Francisco de Assis na Providência de Deus, Bragança Paulista, Brazil
| | | | - Renato G Serpa
- Hospital Santa Casa de Misericórdia de Vitória, Vitória, Brazil
| | | | - Louis N Ohe
- Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | | | - Remo H M Furtado
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - Rogerio Sarmento-Leite
- Instituto de Cardiologia do Rio Grande do Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil
| | | | | | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - Andrei C Sposito
- Department of Internal Medicine, School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | | | - Fernando Bacal
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, São Paulo, Brazil and Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
18
|
Piccolo R, Esposito G. The conundrum of percutaneous coronary intervention without aspirin: a call for clarity. EUROINTERVENTION 2023; 19:13-14. [PMID: 37170566 PMCID: PMC10173752 DOI: 10.4244/eij-e-23-00017] [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: 05/13/2023]
Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| |
Collapse
|