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Birocchi S, Rocchetti M, Minardi A, Podda GM, Squizzato A, Cattaneo M. Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design. Thromb Haemost 2024; 124:482-496. [PMID: 37549688 DOI: 10.1055/a-2149-4344] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND The value of guided therapy (GT) with anti-P2Y12 drugs in percutaneous coronary intervention (PCI) is unclear. Meta-analyses lumped together randomized controlled trials (RCTs) with heterogeneous designs, comparing either genotype-GT or platelet function test (PFT)-GT with unguided therapy. Some meta-analysis also included RCTs that did not explore GT, but included the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy). We performed three distinct systematic reviews/meta-analyses, each exploring only RCTs with homogeneous design. METHODS MEDLINE, Embase, and Central databases were searched for RCTs testing genotype-GT, PFT-GT, or HTPR-Therapy in PCI-treated patients, through October 1, 2022. Two reviewers extracted the data. Risk ratios (RRs) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MBs) and major adverse cardiovascular events (MACE). RESULTS In seven genotype-GT RCTs, RRs were: MB, 1.06 (0.73-1.54; p = 0.76); MACE, 0.65 (0.47-0.91; p = 0.01), but significant risk reduction was observed in RCTs performed in China (0.30, 0.16-0.54; p < 0.0001) and not elsewhere (0.75, 0.48-1.18; p = 0.21). In six PFT-GT RCTs, RRs were: MB, 0.91 (0.64-1.28, p = 0.58); MACE, 0.82 (0.56-1.19; p = 0.30): 0.62 (0.42-0.93; p = 0.02) in China, 1.08 (0.82-1.41; p = 0.53) elsewhere. In eight HTPR-Therapy RCTs, RRs were: MB, 0.71 (0.41-1.23; p = 0.22); MACE, 0.57 (0.44-0.75; p < 0.0001): 0.56 (0.43-0.74, p < 0.0001) in China, 0.58 (0.27-1.23, p = 0.16) elsewhere. CONCLUSION No GT strategy affected MB. Overall, genotype-GT but not PFT-GT reduced MACE. However, genotype-GT and PFT-GT reduced MACE in China, but not elsewhere. PFT-GT performed poorly compared to HTPR-Therapy, likely due to inaccurate identification of HTPR patients by PFT.
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Affiliation(s)
- Simone Birocchi
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Matteo Rocchetti
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Minardi
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Gian Marco Podda
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Marco Cattaneo
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
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Landi A, Gargiulo G, Esposito G, Campo G, Biscaglia S, Heg D, Valgimigli M. Does morphine attenuate the Inhibition of Platelet Aggregation for both oral and parenteral P2Y12 inhibitors? Thromb Res 2024; 237:31-33. [PMID: 38547691 DOI: 10.1016/j.thromres.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/28/2024] [Accepted: 03/12/2024] [Indexed: 04/29/2024]
Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland; The Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland. https://twitter.com/antoniolandii
| | - Giuseppe Gargiulo
- The Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giovanni Esposito
- The Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Gianluca Campo
- The Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy
| | - Simone Biscaglia
- The Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Ferrara, Italy
| | - Dik Heg
- Department of Clinical Research, University of Bern, Switzerland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland; The Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland; The University of Bern, Bern, Switzerland.
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Skalidis I, Petousis S, Koliastasis L, Hamilos M, Skalidis E. Navigating the Role of Ticagrelor in Elective Complex PCI: Time to Rule Out or Reassess? JACC Cardiovasc Interv 2024; 17:1069. [PMID: 38658122 DOI: 10.1016/j.jcin.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 04/26/2024]
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Lattuca B, Silvain J, Vicaut E, Montalescot G. Reply: Navigating the Role of Ticagrelor in Elective Complex PCI: Time to Rule Out or Reassess? JACC Cardiovasc Interv 2024; 17:1070. [PMID: 38658123 DOI: 10.1016/j.jcin.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 04/26/2024]
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Khan MR, Koshy AN, Tanner R, Farhan S, Vinayak M, Farooq A, Sartori S, Feng Y, Spirito A, Arora A, Dhulipala V, Kapur V, Suleman J, Sharma R, Mehran R, Kini A, Sharma SK. Real-World Comparison of Clopidogrel With Ticagrelor and Prasugrel in Patients With Chronic Coronary Disease Who Underwent Atherectomy. Am J Cardiol 2024; 217:1-4. [PMID: 38401658 DOI: 10.1016/j.amjcard.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/09/2024] [Accepted: 02/04/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Mahin R Khan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anoop N Koshy
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Richard Tanner
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Manish Vinayak
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ali Farooq
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yihan Feng
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ayush Arora
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vishal Dhulipala
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vishal Kapur
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Javed Suleman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Raman Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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Jebrin R, El Nekidy WS, Abidi E, John TLS, Kesav P, Hussain SI, Abdelsalam M, Khaled L, Raj D, John S. Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East. Clin Neurol Neurosurg 2024; 239:108167. [PMID: 38402103 DOI: 10.1016/j.clineuro.2024.108167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population. METHODS We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019. RESULTS During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79-12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors. CONCLUSION This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.
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Affiliation(s)
- Rita Jebrin
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Emna Abidi
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Praveen Kesav
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Syed I Hussain
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Luna Khaled
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Divya Raj
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Seby John
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States.
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Wu YJ, Wu CC, Huang HY, Wu CY, Huang CC, Wang CC. Low-dose prasugrel versus standard-dose ticagrelor in east Asian patients with acute coronary syndrome. J Thromb Thrombolysis 2024; 57:537-546. [PMID: 38555552 DOI: 10.1007/s11239-024-02965-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/02/2024]
Abstract
Low-dose prasugrel demonstrated a similar effectiveness profile to clopidogrel in East Asian ACS patients, but its comparison with another new-generation potent P2Y12 inhibitor, ticagrelor, remains unclear. To compare the effectiveness and safety of low-dose prasugrel against those of standard-dose ticagrelor in East Asian patients with ACS. This retrospective cohort study used Taiwan's National Health and Welfare Database. This study included ACS patients who underwent percutaneous coronary intervention and, at discharge between January 1, 2018 and December 31, 2020, were prescribed with low-dose prasugrel plus aspirin or standard-dose ticagrelor plus aspirin. Stabilized inverse probability of treatment weighting was used to balance the covariates across these two groups. The primary effectiveness outcome was a composite of acute myocardial infarction, ischemic stroke, and cardiovascular death; the secondary effectiveness outcome was each of the individual components of the primary outcome, transient ischemic attack, and repeat revascularization. The primary safety outcome was a composite of intracranial hemorrhage and gastrointestinal bleeding, and the two secondary safety outcomes were intracranial hemorrhage and gastrointestinal bleeding. A total of 24,807 patients were included in this study. Among them, 1,493 were low-dose prasugrel users and 23,314 were standard-dose ticagrelor users. No significant differences were found in primary effectiveness [HR: 0.97 (0.74-1.28)] or primary safety outcomes [HR: 1.22 (0.73-2.01)] between the two study groups. For East Asian patients with ACS, low-dose prasugrel provides comparable effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations.
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Affiliation(s)
- Yee-Jen Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan
| | - Hsin-Yi Huang
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan
| | - Chi-Yun Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chuan Wang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan.
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan.
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Çetinarslan Ö, Yenerçağ M, Zoghi M, Ergene AO. Antiplatelet Treatment Preferences of a Group of Cardiologists from Türkiye: A Survey Research Study. Turk Kardiyol Dern Ars 2024; 52:116-124. [PMID: 38465531 DOI: 10.5543/tkda.2023.54778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
OBJECTIVE Deciding on the optimal duration of dual antiplatelet treatment (DAPT) remains a complex decision. This survey aims to explore the preferences for antiplatelet therapy and the daily routine regarding DAPT duration in coronary artery disease among a group of cardiologists in Türkiye. METHOD Using an online questionnaire with 38 questions, the preferences of 314 cardiologists were collected. Qualitative descriptive characteristics of the answers received from the participants were examined. RESULTS Participating cardiologists mostly worked in training and research hospitals (51.59%) and university hospitals (21.66%). Participants primarily favored ticagrelor in patients undergoing PCI with a diagnosis of STEMI and NSTE-ACS (69.75% and 55.73% respectively). Clopidogrel was the most preferred P2Y12 treatment in patients with chronic coronary syndrome (CCS) after PCI (94.90%). Pre-treatment with a loading dose of a P2Y12 receptor inhibitor was administered to 57.01% of patients with NSTE-ACS, irrespective of the planned treatment strategy. In NSTE-ACS patients with low bleeding risk treated with PCI, 83.12% of participants recommended DAPT for 12 months and 14.65% for >12 months. In high-bleeding-risk NSTE-ACS patients treated with PCI, DAPT durations of six months (74.52%), three months (19.75%), and one month (5.73%) were chosen. Among CCS patients treated with PCI without an increased risk of bleeding, 12 months of DAPT was preferred by 68.15% of participants. Most participants (70.70%) were switching to a more potent P2Y12 receptor inhibitor therapy in emergency department clopidogrel-loaded patients with ACS. CONCLUSION The aim of this survey to capture a snapshot of the preferences of a group of cardiologists in Türkiye regarding DAPT treatment and duration. The responses were both in accordance and in conflict with the current guidelines.
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Affiliation(s)
- Özge Çetinarslan
- Department of Cardiology, Liv Hospital, Vadi İstanbul, İstanbul, Türkiye
| | - Mustafa Yenerçağ
- Department of Cardiology, Ordu University Faculty of Medicine, Türkiye
| | - Mehdi Zoghi
- Department of Cardiology, Ege University, Faculty of Medicine, Türkiye
| | - Asım Oktay Ergene
- Department of Cardiology, Dokuz Eylül University, Faculty of Medicine, Türkiye
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Lozano I, Vegas JM, Rondan J. Frailty and P2Y12 Inhibitors: Does The Best Approach Need to Be Black or White? Am J Cardiol 2024; 213:186. [PMID: 38142879 DOI: 10.1016/j.amjcard.2023.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Iñigo Lozano
- Department of Cardiology, Hospital Cabueñes, Gijón, Spain.
| | - Jose M Vegas
- Department of Cardiology, Hospital Cabueñes, Gijón, Spain
| | - Juan Rondan
- Department of Cardiology, Hospital Cabueñes, Gijón, Spain
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Amoafo EB, Entsie P, Kang Y, Canobbio I, Liverani E. Platelet P2Y 12 signalling pathway in the dysregulated immune response during sepsis. Br J Pharmacol 2024; 181:532-546. [PMID: 37525937 PMCID: PMC10830899 DOI: 10.1111/bph.16207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
Sepsis is a complicated pathological condition in response to severe infection. It is characterized by a strong systemic inflammatory response, where multiple components of the immune system are involved. Currently, there is no treatment for sepsis. Blood platelets are known for their role in haemostasis, but they also participate in inflammation through cell-cell interaction and the secretion of inflammatory mediators. Interestingly, an increase in platelet activation, secretion, and aggregation with other immune cells (such as monocytes, T-lymphocytes and neutrophils) has been detected in septic patients. Therefore, antiplatelet therapy in terms of P2Y12 antagonists has been evaluated as a possible treatment for sepis. It was found that blocking P2Y12 receptors decreased platelet marker expression and limited attachment to immune cells in some studies, but not in others. This review addresses the role of platelets in sepsis and discusses whether antagonizing P2Y12 signalling pathways can alter the disease outcome. Challenges in studying P2Y12 antagonists in sepsis also are discussed. LINKED ARTICLES: This article is part of a themed issue on Platelet purinergic receptor and non-thrombotic disease. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.4/issuetoc.
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Affiliation(s)
- Emmanuel Boadi Amoafo
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Philomena Entsie
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Ying Kang
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Ilaria Canobbio
- Department of Biology and Biotechnology, University of Pavia, Pavia, Italy
| | - Elisabetta Liverani
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
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Andò G, Gragnano F, Pelliccia F, Calabrò P. Choice of P2Y12 Inhibitors After Acute Coronary Syndrome. Am J Cardiol 2024; 211:377. [PMID: 37944777 DOI: 10.1016/j.amjcard.2023.10.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "G. Martino", Messina, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" and Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University of Rome "La Sapienza", Rome, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" and Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
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Bates ER. Clinically Significant Differences Between P2Y 12 Inhibitor Monotherapy and Aspirin Monotherapy Have Yet to Be Demonstrated. J Am Coll Cardiol 2024; 83:e9-e10. [PMID: 38171716 DOI: 10.1016/j.jacc.2023.09.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/22/2023] [Indexed: 01/05/2024]
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Mostafa MR, Abdou C, Barssoum K, Jneid H. Aspirin vs P2Y 12 Inhibitors: A Few Questions Unanswered. J Am Coll Cardiol 2024; 83:e7. [PMID: 38171715 DOI: 10.1016/j.jacc.2023.09.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 01/05/2024]
Affiliation(s)
| | | | | | - Hani Jneid
- University of Texas Medical Branch, Galveston, Texas, USA
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15
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Roule V, Beygui F, Cayla G, Rangé G, Motovska Z, Delarche N, Jourda F, Goube P, Guedeney P, Zeitouni M, El Kasty M, Laredo M, Dumaine R, Ducrocq G, Derimay F, Van Belle E, Manigold T, Cador R, Combaret N, Vicaut E, Montalescot G, Silvain J. P2Y 12 Inhibitor Loading Time Before Elective PCI and the Prevention of Myocardial Necrosis. Can J Cardiol 2024; 40:31-39. [PMID: 37660934 DOI: 10.1016/j.cjca.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND There are dated and conflicting data about the optimal timing of initiation of P2Y12 inhibitors in elective percutaneous coronary intervention (PCI). Peri-PCI myocardial necrosis is associated with poor outcomes. We aimed to assess the impact of the P2Y12 inhibitor loading time on periprocedural myocardial necrosis in the population of the randomized Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting (ALPHEUS) trial, which compared ticagrelor with clopidogrel in high-risk patients who received elective PCI. METHODS The ALPHEUS trial divided 1809 patients into quartiles of loading time. The ALPHEUS primary outcome was used (type 4 [a or b] myocardial infarction or major myocardial injury) as well as the main secondary outcome (type 4 [a or b] myocardial infarction or any type of myocardial injury). RESULTS Patients in the first quartile group (Q1) presented higher rates of the primary outcome (P = 0.01). When compared with Q1, incidences of the primary outcome decreased in patients with longer loading times (adjusted odds ratio [adjOR], 0.70 [0.52.-0.95]; P = 0.02 for Q2; adjOR 0.65 [0.48-0.88]; P < 0.01 for Q3; adjOR 0.66 [0.49-0.89]; P < 0.01 for Q4). Concordant results were found for the main secondary outcome. There was no interaction with the study drug allocated by randomization (clopidogrel or ticagrelor). Bleeding complications (any bleeding ranging between 4.9% and 7.3% and only 1 major bleeding at 48 hours) and clinical ischemic events were rare and did not differ among groups. CONCLUSIONS In elective PCI, administration of the oral P2Y12 inhibitor at the time of PCI could be associated with more frequent periprocedural myocardial necrosis than an earlier administration. The long-term clinical consequences remain unknown.
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Affiliation(s)
- Vincent Roule
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France; Département de Cardiologie, CHU de Caen, Caen, France
| | - Farzin Beygui
- Département de Cardiologie, CHU de Caen, Caen, France
| | - Guillaume Cayla
- Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION Study Group, Nîmes, France
| | - Grégoire Rangé
- Département de Cardiologie, CH de Chartres, Chartres, France
| | - Zuzana Motovska
- Cardiocentre, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | | | | | - Pascal Goube
- Service de Cardiologie, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
| | - Paul Guedeney
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Michel Zeitouni
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Mohamad El Kasty
- Department of Cardiology, Grand Hôpital de l'Est Francilien, Jossigny, France
| | - Mikael Laredo
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Raphaëlle Dumaine
- Les Grands Prés Cardiac Rehabilitation Centre, Villeneuve St Denis, France
| | - Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - François Derimay
- Service de Cardiologie Interventionnelle, Hospices Civils de Lyon and CARMEN INSERM 1060, Lyon, France
| | - Eric Van Belle
- CHU Lille, Institut Cœur Poumon, Cardiology, and Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, INSERM U1011, Institut Pasteur de Lille, EGID, Université de Lille, Lille, France
| | | | - Romain Cador
- Department of Cardiology Saint Joseph Hospital, Paris, France
| | - Nicolas Combaret
- Department of Cardiology, Clermont-Ferrand University Hospital, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Eric Vicaut
- Unité de Recherche Clinique, ACTION Study Group, Hôpital Fernand Widal (AP-HP), Paris, France and SAMM (Statistique, Analyse et Modélisation Multidisciplinaire) EA 4543, Université Paris 1 Panthéon, Sorbonne, France
| | - Gilles Montalescot
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France. http://www.action-cœur.org
| | - Johanne Silvain
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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16
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes. Pharmacoepidemiol Drug Saf 2024; 33:e5704. [PMID: 37771242 DOI: 10.1002/pds.5704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors. METHODS We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression. RESULTS We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS. CONCLUSIONS We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.
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Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California, USA
| | | | - Maneesh Sud
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Akyuz S, Calik AN, Yaylak B, Onuk T, Eren S, Kolak Z, Mollaalioglu F, Durak F, Cetin M, Tanboga IH. Comparison of Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome at High Bleeding or Ischemic Risk. Am J Cardiol 2024; 210:241-248. [PMID: 37875237 DOI: 10.1016/j.amjcard.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/03/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023]
Abstract
Current guidelines recommend individualizing the choice and duration of P2Y12 inhibitor therapy based on the trade-off between bleeding and ischemic risk. However, whether a potent P2Y12 inhibitor (ticagrelor) or a less potent one (clopidogrel) is more appropriate in patients with acute coronary syndrome (ACS) in the setting of high bleeding or ischemic risk is not clear. The study aimed to compare the clinical outcomes of clopidogrel and ticagrelor in patients with ACS at high bleeding or ischemic risk. A total of 5,713 patients with ACS were included in this retrospective study. The Cox proportional hazard regression model was adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The primary clinical outcome was all-cause death. Secondary outcomes included in-hospital death, ACS, target vessel revascularization, stent thrombosis, stroke, or clinically significant or major bleeding. The median follow-up duration was 53.6 months. After multivariable Cox model using an inverse probability weighted approach, all-cause death in the overall population and subgroups of patients at high bleeding risk, and/or at high ischemic risk were not significantly different between clopidogrel and ticagrelor. Rates for secondary outcomes were also similar between the groups. In conclusion, ticagrelor and clopidogrel are associated with comparable clinical outcomes in patients with ACS irrespective of bleeding and ischemic risk.
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Affiliation(s)
- Sukru Akyuz
- Department of Cardiology, Okan University Faculty of Medicine, Istanbul, Turkey.
| | - Ali Nazmi Calik
- Department of Cardiology, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Baris Yaylak
- Department of Cardiology, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tolga Onuk
- Department of Cardiology, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Semih Eren
- Department of Cardiology, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Zeynep Kolak
- Department of Cardiology, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Feyza Mollaalioglu
- Department of Cardiology, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Furkan Durak
- Department of Cardiology, Ilhan Varank Sancaktepe Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Cetin
- Department of Cardiology, Recep Tayyip Erdogan University Training and Research Hospital, Rize, Turkey
| | - Ibrahim Halil Tanboga
- Department of Biostatistics, Nisantasi University Medical School, Istanbul, Turkey; Department of Cardiology, Hisar Intercontinental Hospital, Istanbul, Turkey
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18
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Galli M, Angiolillo DJ. Role of the P2Y12 receptor on thrombus formation and evolution in therapeutic strategies. Expert Opin Ther Targets 2024; 28:5-8. [PMID: 38315098 DOI: 10.1080/14728222.2024.2315017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024]
Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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19
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Mangiacapra F, Colaiori I, Di Gioia G, Pellicano M, Heyse A, Paolucci L, Peace A, Bartunek J, de Bruyne B, Barbato E. Effects of ticagrelor and prasugrel on coronary microcirculation in elective percutaneous coronary intervention. Heart 2023; 110:115-121. [PMID: 37316163 DOI: 10.1136/heartjnl-2022-321868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/29/2023] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To compare the effects of ticagrelor and prasugrel on absolute coronary blood flow (Q) and microvascular resistance (R) in patients with stable coronary artery disease (CAD) treated with elective percutaneous coronary intervention (PCI) (NCT05643586). Besides being at least as effective as prasugrel in inhibiting platelet aggregation, ticagrelor has been shown to have additional properties potentially affecting coronary microcirculation. METHODS We randomly assigned 50 patients to ticagrelor (180 mg) or prasugrel (60 mg) at least 12 hours before intervention. Continuous thermodilution was used to measure Q and R before and after PCI. Platelet reactivity was measured before PCI. Troponin I was measured before, 8 and 24 hours after PCI. RESULTS At baseline, fractional flow reserve, Q and R were similar in two study groups. Patients in the ticagrelor group showed higher post-PCI Q (242±49 vs 205±53 mL/min, p=0.015) and lower R values (311 (263, 366) vs 362 (319, 382) mm Hg/L/min, p=0.032). Platelet reactivity showed a negative correlation with periprocedural variation of Q values (r=-0.582, p<0.001) and a positive correlation with periprocedural variation of R values (r=0.645, p<0.001). The periprocedural increase in high-sensitivity troponin I was significantly lower in the ticagrelor compared with the prasugrel group (5 (4, 9) ng/mL vs 14 (10, 24) ng/mL, p<0.001). CONCLUSIONS In patients with stable CAD undergoing PCI, pretreatment with a loading dose of ticagrelor compared with prasugrel improves post-procedural coronary flow and microvascular function and seems to reduce the related myocardial injury.
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Affiliation(s)
- Fabio Mangiacapra
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Iginio Colaiori
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | | | | | - Alex Heyse
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | - Luca Paolucci
- Research Unit of Cardiovascular Science, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Jozef Bartunek
- Cardiovasciular Research Center Aalst, OLV Hospital, Aalst, Belgium
| | | | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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Lofrumento F, Irrera N, Licordari R, Perfetti S, Nasso E, Liotta P, Isgrò G, Garcia-Ruiz V, Squadrito F, Carerj S, Di Bella G, Micari A, Costa F. Off-Target Effects of P2Y12 Receptor Inhibitors: Focus on Early Myocardial Fibrosis Modulation. Int J Mol Sci 2023; 24:17546. [PMID: 38139379 PMCID: PMC10743395 DOI: 10.3390/ijms242417546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
Several studies have demonstrated that, beyond their antithrombotic effects, P2Y12 receptor inhibitors may provide additional off-target effects through different mechanisms. These effects range from the preservation of endothelial barrier function to the modulation of inflammation or stabilization of atherosclerotic plaques, with an impact on different cell types, including endothelial and immune cells. Many P2Y12 inhibitors have been developed, from ticlopidine, the first thienopyridine, to the more potent non-thienopyridine derivatives such as ticagrelor which may promote cardioprotective effects following myocardial infarction (MI) by inhibiting adenosine reuptake through sodium-independent equilibrative nucleoside transporter 1 (ENT1). Adenosine may affect different molecular pathways involved in cardiac fibrosis, such as the Wnt (wingless-type)/beta (β)-catenin signaling. An early pro-fibrotic response of the epicardium and activation of cardiac fibroblasts with the involvement of Wnt1 (wingless-type family member 1)/β-catenin, are critically required for preserving cardiac function after acute ischemic cardiac injury. This review discusses molecular signaling pathways involved in cardiac fibrosis post MI, focusing on the Wnt/β-catenin pathway, and the off-target effect of P2Y12 receptor inhibition. A potential role of ticagrelor was speculated in the early modulation of cardiac fibrosis, thanks to its off-target effect.
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Affiliation(s)
- Francesca Lofrumento
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Roberto Licordari
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Silvia Perfetti
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Enrica Nasso
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Paolo Liotta
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Giovanni Isgrò
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | | | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (F.L.); (R.L.); (S.P.); (E.N.); (P.L.); (G.I.); (F.S.); (S.C.); (G.D.B.)
| | - Antonio Micari
- BIOMORF Department, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | - Francesco Costa
- BIOMORF Department, Policlinic “G. Martino”, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
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Cayla G, Lattuca B. De-escalation from potent P2Y12 inhibitors to clopidogrel: an alternative to short DAPT duration in HBR patients? EUROINTERVENTION 2023; 19:e789-e791. [PMID: 38050993 PMCID: PMC10687644 DOI: 10.4244/eij-e-23-00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Guillaume Cayla
- Department of Cardiology, Nimes University Hospital, Montpellier University, ACTION study group, Nimes, France
| | - Benoit Lattuca
- Department of Cardiology, Nimes University Hospital, Montpellier University, ACTION study group, Nimes, France
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22
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Mi X, Ni C, Zhao J, Amin N, Jiao D, Fang M, Ye X. P2Y12 receptor mediates apoptosis and demyelination to affect functional recovery in mice with spinal cord injury. Neurochem Int 2023; 171:105641. [PMID: 37952830 DOI: 10.1016/j.neuint.2023.105641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/28/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
Among diseases of the central nervous system (CNS), spinal cord injury (SCI) has a high fatality rate. It has been proven that P2Y G protein-coupled purinergic receptors have a neuroprotective role in apoptosis and regeneration inside the damaged spinal cord. The P2Y12 receptor (P2Y12R) has recently been linked to peripheral neuropathy and stroke. However, the role of P2Y12R after SCI remains unclear. Our study randomly divided C57BL/6J female mice into 3 groups: Sham+DMSO, SCI+DMSO, and SCI+MRS2395. MRS2395 as a P2Y12R inhibitor was intraperitoneally injected at a dose of 1.5 mg/kg once daily for 7 days. We showed that the P2Y12R was markedly activated after injury, and it was double labeled with the microglial and neuron. Behavioral tests were employed to assess motor function recovery. By using immunofluorescence staining, the NeuN expression level was detected. The morphology of neurons was observed by hematoxylin-eosin and Nissl staining. P2Y12R, Bax, GFAP, PCNA and calbindin expression levels were detected using Western blot. Meanwhile, mitochondria and myelin sheath were observed by transmission electron microscopy (TEM). Our findings demonstrated that MRS2395 significantly enhanced motor function induced by SCI and that was used to alleviate apoptosis and astrocyte scarring. NeuN positive cells in the SCI group were lower than in the therapy group, although Bax, GFAP, PCNA and calbindin expression levels were considerably higher. Moreover, following MRS2395 therapy, the histological damage was reversed. A notable improvement in myelin sheath and mitochondrial morphology was seen in the therapy group. Together, our findings indicate that activation of P2Y12R in damaged spinal cord may be a critical event and suggest that inhibition of P2Y12R might be a feasible therapeutic strategy for treating SCI.
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Affiliation(s)
- Xiaodan Mi
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, 310014, China
| | - Chengtao Ni
- Graduate School, Bengbu Medical College, Bengbu, Anhui, China
| | - Jingting Zhao
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, 310014, China
| | - Nashwa Amin
- Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, 310014, China; Institute of System Medicine, Zhejiang University School of Medicine, Hangzhou, China; Department of Zoology, Faculty of Science, Aswan University, Egypt
| | - Dian Jiao
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, China
| | - Marong Fang
- Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China.
| | - Xiangming Ye
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People's Hospital Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, 310014, China.
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23
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Gegri M, Cheves TA, Anderson MN, McTaggart R, Sweeney JD. Discordance in tests used to detect inhibition of the P2Y12 receptor in patients undergoing interventional neuroradiology procedures. Interv Neuroradiol 2023; 29:655-664. [PMID: 36039509 PMCID: PMC10680952 DOI: 10.1177/15910199221122858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Clopidogrel is an inhibitor of the P2Y12 platelet receptor but testing to demonstrate a drug effect is controversial since there are often discordant results between different tests methods. METHODS Samples from patients taking clopidogrel prior to intracranial flow-diversion procedures were tested using light transmission aggregometry (LTA), whole blood impedance aggregometry (WBIA) and the VerifyNow device (VND). Samples were classified as concordant if all test results were either responsive (inhibition) or resistant. Discordant results were separated using the VND into those with a responsive versus a resistant test result. RESULTS Samples from 96 patients were studied. Concordance for all three tests was seen in 53/96 (55%) of samples, of which 41 (43%) were responsive and 12 (12%) were resistant. Discordance was observed in 43 samples (45%), 37 (28%) of which were caused by responsive VND and either a resistant WBIA or LTA and 6 (7%) of which were caused by a resistant VND but a responsive test result using either WBIA or LTA. These two discordant groups differed in both platelet count and hematocrit, but no such difference was present between the two concordant groups. CONCLUSION Discordance in P2Y12 inhibition testing may be partly explained by sample platelet count and hematocrit.
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Affiliation(s)
- Mansour Gegri
- Departments of Coagulation and Transfusion Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Tracey A Cheves
- Departments of Coagulation and Transfusion Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Matthew N Anderson
- Departments of Neurosurgery, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Ryan McTaggart
- Departments of Diagnostic Imaging, Rhode Island Hospital, Providence, RI, USA
- Departments of Neurology, Rhode Island Hospital, Providence, RI, USA
- Departments of Neurosurgery, Warren Alpert School of Medicine at Brown University, Rhode Island Hospital, Providence, RI, USA
- The Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, RI, USA
| | - Joseph D Sweeney
- Departments of Coagulation and Transfusion Medicine, Rhode Island Hospital, Providence, RI, USA
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24
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Ko D, Pande A, Lin KJ, Cervone A, Bessette LG, Lee SB, Cheng S, Glynn RJ, Kim DH. Utilization of P2Y 12 Inhibitors in Older Adults With ST-Elevation Myocardial Infarction and Frailty. Am J Cardiol 2023; 207:245-252. [PMID: 37757521 PMCID: PMC10840744 DOI: 10.1016/j.amjcard.2023.08.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/06/2023] [Accepted: 08/13/2023] [Indexed: 09/29/2023]
Abstract
Choosing optimal P2Y12 inhibitor in frail older adults is challenging because they are at increased risk of both ischemic and bleeding events. We conducted a retrospective cohort study of Medicare Advantage Plan beneficiaries who were prescribed clopidogrel, prasugrel, or ticagrelor after percutaneous coronary intervention-treated ST-elevation myocardial infarction from January 1, 2010 to December 31, 2020. Frailty was defined using claims-based frailty index ≥0.25. We conducted multivariable logistic regression to identify factors associated with using potent P2Y12 inhibitors and multivariable-adjusted competing risk analyses to compare the rate of discontinuation of potent P2Y12 inhibitors in frail versus non-frail patients. There were 11,239 patients (mean age 74 years, 39% women). The prevalence of cardiovascular and geriatric co-morbidities was as follows: 32% chronic kidney disease, 28% heart failure, 10% previous myocardial infarction, 6% dementia, 20% anemia, and 12% frailty. The proportion of patients receiving clopidogrel decreased from 78.3% in 2010 to 2013 to 42.1% in 2018 to 2020, with a concurrent increase in those receiving potent P2Y12 inhibitors (mostly ticagrelor) from 21.7% to 57.9%. Frailty was independently associated with reduced odds of initiation (odds ratio 0.78, 95% confidence interval 0.67 to 0.90) but not with discontinuation of potent P2Y12 inhibitors (subdistribution hazard ratio 1.09, 95% confidence interval 0.98 to 1.22). In conclusion, frail older adults are less likely to receive potent P2Y12 inhibitors after percutaneous coronary intervention-treated ST-elevation myocardial infarction, but they are as likely as non-frail patients to continue with the prescribed P2Y12 inhibitor.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts; Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Ashvin Pande
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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25
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Shah RP, Shafiq A, Hamza M, Maniya MT, Duhan S, Keisham B, Patel B, Alamzaib SM, Yashi K, Uppal D, Sattar Y, Tiwari D, Paul TK, AlJaroudi W, Alraies MC. Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 207:206-214. [PMID: 37751668 DOI: 10.1016/j.amjcard.2023.08.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Limited data comparing prasugrel and ticagrelor in acute coronary syndrome are available. Online databases, including MEDLINE and Cochrane Central, were queried to compare these drugs. The primary outcomes of this meta-analysis are myocardial infarction (MI), all-cause mortality, cardiovascular mortality, noncardiovascular mortality, stent thrombosis, and stroke. The secondary outcome is major bleeding. A total of 9 studies, including 94,590 patients (prasugrel group = 32,759; ticagrelor group = 61,831), were included in this meta-analysis. The overall mean age was 62.73 years, whereas the mean age for the ticagrelor and prasugrel groups was 63.80 and 61.65 years, respectively. Prasugrel is equally effective as compared with ticagrelor in preventing MI. There was no difference between the 2 groups regarding all-cause mortality, stent thrombosis, stroke, or major bleeding. In patients with acute coronary syndrome, prasugrel is equally effective when compared with ticagrelor in preventing MI.
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Affiliation(s)
- Rajendra P Shah
- Department of Cardiology, University of Florida/Malcom Randall Veterans Affairs Medical Center, Florida, USA
| | - Aimen Shafiq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammad Hamza
- Department of Medicine, Albany Medical Center, Albany, New York, USA
| | | | - Sanchit Duhan
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Bijeta Keisham
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Bansari Patel
- Department of Medicine, West Virginia University, West Virginia, USA
| | | | - Kanica Yashi
- Department of Medicine, Bassett Healthcare, New York, USA
| | - Dipan Uppal
- Department of Cardiology, Cleveland Clinic Florida, Florida, USA
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Dinesh Tiwari
- Department of Dermatology, Mayo Institute of Medical Sciences, Uttar Pradesh, India
| | - Timir K Paul
- Department of Cardiology, University of Tennessee Health Sciences Center, Nashville, Tennessee, USA
| | - Wael AlJaroudi
- Division of Cardiology, Medical College of Georgia at Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - M Chadi Alraies
- Department of Cardiology, Cardiovascular Institute, Detroit Medical Center, Detroit, Michigan, USA.
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26
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Jang MH, Kim AR, Kim T, Oh HJ, Lee JH, Lee YJ, Kim S, Lee J, Kim JH, Cha SJ, Kim TO, Kang DY, Lee PH, Ahn JM, Park DW, Park SJ. Age- and Sex-Specific Disparities in Outcomes After Ticagrelor Versus Clopidogrel in East Asian Patients. Am J Cardiol 2023; 207:237-244. [PMID: 37757520 DOI: 10.1016/j.amjcard.2023.08.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023]
Abstract
It is unknown whether there are age- and gender-related differences in the safety and efficacy of potent P2Y12 inhibitors in East Asian populations with a different bleeding or ischemic propensity. Using data from the TICAKOREA (Ticagrelor Versus Clopidogrel in Asian/Korean Patients with ACS Intended for Invasive Management) trial comparing ticagrelor versus clopidogrel for 800 Korean patients with acute coronary syndrome, the safety and efficacy outcomes were compared according to age (<75 vs ≥75 years) and gender (men vs women). The primary bleeding end point was clinically significant bleeding, and the primary ischemic end point was a major adverse cardiovascular event (MACE) at 12 months. The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in patients aged <75 years (adjusted hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.40 to 4.67) but not in patients aged ≥75 years (adjusted HR 1.1, 95% CI 0.40 to 3.38). The incidences of MACEs were significantly higher after ticagrelor than after clopidogrel in patients aged ≥75 years (adjusted HR 6.14, 95% CI 1.40 to 26.90) but not in patients aged <75 years (adjusted HR 0.93, 95% CI 0.50 to 1.73). The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in men (adjusted HR 2.69, 95% CI 1.38 to 5.24) but not in women (adjusted HR 1.49, 95% CI 0.64 to 3.46). The adjusted risks of MACEs after ticagrelor or clopidogrel were not significantly different between men and women. In conclusion, there were substantial age- and gender-related differences in bleeding and ischemic outcomes after ticagrelor or clopidogrel in Korean patients with acute coronary syndrome. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique identifier: NCT02094963.
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Affiliation(s)
- Mi Hee Jang
- Department of Cardiology, Ulsan University Hospital, Ulsan, Korea
| | - Ah-Ram Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taesun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon Jeong Oh
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeen Hwa Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Jeong Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyeon Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Joo Cha
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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27
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Tannu M, Newby LK. In CAD, P2Y12 inhibitor vs. aspirin monotherapy reduces a composite CV outcome without increasing major bleeding. Ann Intern Med 2023; 176:JC123. [PMID: 37931259 DOI: 10.7326/j23-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
SOURCE CITATION Gragnano F, Cao D, Pirondini L, et al; PANTHER Collaboration. P2Y12 inhibitor or aspirin monotherapy for secondary prevention of coronary events. J Am Coll Cardiol. 2023;82:89-105. 37407118.
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Affiliation(s)
- Manasi Tannu
- Duke University School of Medicine, Durham, North Carolina, USA (M.T., L.K.N.)
| | - L Kristin Newby
- Duke University School of Medicine, Durham, North Carolina, USA (M.T., L.K.N.)
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28
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Girotra S, Stebbins A, Wruck L, Marquis‐Gravel G, Gupta K, Farrehi P, Benziger CP, Effron MB, Whittle J, Muñoz D, Kripalani S, Anderson RD, Jain SK, Polonsky TS, Ahmad FS, Roe MT, Rothman RL, Harrington RA, Hernandez AF, Jones WS. Aspirin Dosing for Secondary Prevention of Atherosclerotic Cardiovascular Disease in Patients Treated With P2Y12 Inhibitors. J Am Heart Assoc 2023; 12:e030385. [PMID: 37830344 PMCID: PMC10757508 DOI: 10.1161/jaha.123.030385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023]
Abstract
Background The ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) was a large, pragmatic, randomized controlled trial that found no difference between high- versus low-dose aspirin for secondary prevention of atherosclerotic cardiovascular disease. Whether concomitant P2Y12 inhibitor therapy modifies the effect of aspirin dose on clinical events remains unclear. Methods and Results Participants in ADAPTABLE were stratified according to baseline use of clopidogrel or prasugrel (P2Y12 group). The primary effectiveness end point was a composite of death, myocardial infarction, or stroke; and the primary safety end point was major bleeding requiring blood transfusions. We used multivariable Cox regression to compare the relative effectiveness and safety of aspirin dose within P2Y12 and non-P2Y12 groups. Of 13 815 (91.6%) participants with available data, 3051 (22.1%) were receiving clopidogrel (2849 [93.4%]) or prasugrel (203 [6.7%]) at baseline. P2Y12 inhibitor use was associated with higher risk of the primary effectiveness end point (10.86% versus 6.31%; adjusted hazard ratio [HR], 1.40 [95% CI, 1.22-1.62]) but was not associated with bleeding (0.95% versus 0.53%; adjusted HR, 1.42 [95% CI, 0.91-2.22]). We found no interaction in the relative effectiveness and safety of high- versus low-dose aspirin by P2Y12 inhibitor use. Overall, dose switching or discontinuation was more common in the high-dose compared with low-dose aspirin group, but the pattern was not modified by P2Y12 inhibitor use. Conclusions In this prespecified analysis of ADAPTABLE, we found that the relative effectiveness and safety of high- versus low-dose aspirin was not modified by baseline P2Y12 inhibitor use. Registration https://www.clinical.trials.gov. Unique identifier: NCT02697916.
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Affiliation(s)
- Saket Girotra
- University of Texas Southwestern Medical CenterDallasTX
| | - Amanda Stebbins
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
| | - Lisa Wruck
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
| | | | - Kamal Gupta
- University of Kansas Medical CenterKansas CityKS
| | | | | | | | | | | | | | | | | | | | - Faraz S. Ahmad
- Northwestern University Feinberg School of MedicineChicagoIL
| | - Matthew T. Roe
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
| | | | | | | | - W. Schuyler Jones
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
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29
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Woelders ECI, Luijkx JJP, Rodwell L, Winkler PJC, Dimitriu-Leen AC, Smits PC, van Royen N, Hof AWJV, Damman P, van Geuns RJM. Outcomes with P2Y12 inhibitor monotherapy after PCI according to bleeding risk: A Bayesian meta-analysis. Cardiovasc Revasc Med 2023; 55:44-51. [PMID: 37188619 DOI: 10.1016/j.carrev.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND P2Y12 inhibitor monotherapy is a promising novel strategy to reduce bleeding complications compared to dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI). In order to personalise treatment with DAPT based on patients' bleeding risk, we compared outcomes after PCI between P2Y12 inhibitor monotherapy and DAPT according to bleeding risk. METHODS A search for randomized clinical trials (RCTs) comparing P2Y12 inhibitor monotherapy after a short period of DAPT to standard DAPT after PCI was performed. Outcome differences between treatment groups regarding major bleedings, major adverse cardiac and cerebral events (MACCE) and net adverse clinical events (NACE) were assessed with hazard ratios (HRs) and corresponding credible intervals (CrI) according a Bayesian random effects model in patients with and without high bleeding risk (HBR). RESULTS Five RCTs including 30,084 patients were selected. P2Y12 inhibitor monotherapy compared to DAPT reduced major bleedings in the total population (HR: 0.65, 95 % CrI: 0.44 to 0.92). The HRs of the HBR and non-HBR subgroups showed a similar reduction of bleedings for monotherapy (HBR: HR 0.66, 95 % CrI: 0.25 to 1.74; non-HBR: HR 0.63, 95 % CrI: 0.36 to 1.09). No notable differences between treatments on MACCE and NACE were observed in either sub-group or in the total population. CONCLUSIONS Regardless of bleeding risk, P2Y12 inhibitor monotherapy is the favourable choice after PCI regarding major bleedings and does not increase ischemic events compared to DAPT. This suggests that bleeding risk is not decisive when considering P2Y12 inhibitor monotherapy.
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Affiliation(s)
- Eva C I Woelders
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jasper J P Luijkx
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Laura Rodwell
- Radboud Institute for Health Sciences, Health Evidence, Section Biostatistics, Nijmegen, the Netherlands
| | - Patty J C Winkler
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Arnoud W J Van't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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30
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Piccolo R, Avvedimento M, Canonico ME, Gargiulo P, Paolillo R, Conti V, Dal Piaz F, Filippelli A, Morisco C, Simonetti F, Leone A, Marenna A, Bruzzese D, Gargiulo G, Stabile E, Di Serafino L, Franzone A, Cirillo P, Esposito G. Platelet Inhibition with Ticagrelor 60 mg Versus 90 mg Twice Daily in Elderly Patients with Acute Coronary Syndrome: Rationale and Design of the PLINY THE ELDER Trial. Cardiovasc Drugs Ther 2023; 37:1031-1038. [PMID: 35048203 DOI: 10.1007/s10557-021-07302-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Elderly status is steadily increasing among patients with acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 receptor inhibitor is the cornerstone of treatment to prevent recurrent thrombotic complications in patients with ACS. However, DAPT in older patients is challenged by a concurrent heightened risk of ischemia and bleeding. The aim of this study is to evaluate the pharmacodynamic and pharmacokinetic profile of a lower dose of ticagrelor (60 mg twice daily) among elderly patients during the early phase of ACS. STUDY DESIGN PLINY THE ELDER (PLatelet INhibition with two different doses of potent P2y12 inhibitors in THE ELDERly population) (NCT04739384) is a prospective, randomized, open-label, crossover trial to evaluate the non-inferiority of a lower dose of ticagrelor (60 mg twice daily) compared with a standard dose (90 mg twice daily) among elderly patients with ACS undergoing percutaneous coronary intervention (PCI). A total of 50 patients, aged 75 years or more, with indication to potent P2Y12 receptor inhibitors will be randomized within 3 days from PCI for the index ACS. Patients with indication to oral anticoagulant therapy, treatment with glycoprotein IIb/IIIa inhibitors, or active bleeding will be excluded. The primary endpoint is platelet reactivity determined by P2Y12 reaction units (PRU) (VerifyNow, Accumetrics, San Diego, CA, USA) after treatment with ticagrelor 60 or 90 mg twice daily for 14 days. Secondary endpoints will include other pharmacodynamic tests of ADP-induced aggregation (light transmittance aggregometry and multiple electrode aggregometry) and determination of pharmacokinetic profile (plasma levels of ticagrelor and its metabolite AR-C124910XX) by high performance liquid chromatography-tandem mass spectrometry. CONCLUSIONS The PLINY THE ELDER trial will determine whether a lower dose of ticagrelor confers non-inferior platelet inhibition compared with the standard dose in the early phase of ACS among elderly patients undergoing PCI, informing future clinical investigation.
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Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy.
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Mario Enrico Canonico
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Paola Gargiulo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Valeria Conti
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
- Department of Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
- Department of Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
- Department of Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Carmine Morisco
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Fiorenzo Simonetti
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Alessandra Marenna
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Dario Bruzzese
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
- UNESCO Chair On Health Education and Sustainable Development, University of Naples Federico II, Naples, Italy
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31
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Gomes DA, Rocha BM, Ferreira J, Paiva MS, Reis Santos R, Santos MR, Cunha G, DE Araújo Gonçalves P, Fevereiro S, Trabulo M, Aguiar C, Sousa-Uva M, Neves J, Mendes M. Pretreatment with a P2Y12 receptor inhibitor and delay to coronary artery bypass surgery in patients with non-ST segment elevation acute coronary syndrome. Minerva Cardiol Angiol 2023; 71:582-589. [PMID: 36475547 DOI: 10.23736/s2724-5683.22.06199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND 2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS. METHODS Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded. RESULTS The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding. CONCLUSIONS Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.
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Affiliation(s)
- Daniel A Gomes
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal -
| | - Bruno M Rocha
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Jorge Ferreira
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Mariana S Paiva
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Rita Reis Santos
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Marina R Santos
- Department of Cardiology, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Gonçalo Cunha
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Pedro DE Araújo Gonçalves
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Susana Fevereiro
- Department of Hemotherapy, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Marisa Trabulo
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Carlos Aguiar
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Sousa-Uva
- Department of Cardio-Thoracic Surgery, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - José Neves
- Department of Cardio-Thoracic Surgery, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Mendes
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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Sotomi Y, Matsuoka Y, Hikoso S, Nakatani D, Okada K, Dohi T, Kida H, Oeun B, Sunaga A, Sato T, Kitamura T, Sakata Y. P2Y12 inhibitor monotherapy after complex percutaneous coronary intervention: a systematic review and meta-analysis of randomized clinical trials. Sci Rep 2023; 13:12608. [PMID: 37537330 PMCID: PMC10400615 DOI: 10.1038/s41598-023-39213-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023] Open
Abstract
It remains unknown whether the recent trend of short dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy can simply be applied to patients undergoing complex percutaneous coronary intervention (PCI). We performed a systematic review and meta-analysis to evaluate P2Y12 inhibitor monotherapy vs. conventional DAPT in patients undergoing complex PCI and non-complex PCI (PROSPERO: CRD42022335723). Primary endpoint was the 1-year Net Adverse Clinical Event (NACE). Among 5,323 screened studies, six randomized trials fulfilled the eligibility criteria. A total of 10,588 complex PCI patients (5,269 vs. 5,319 patients) and 25,618 non-complex PCI patients (12,820 vs 12,798 patients) were randomly assigned to P2Y12 inhibitor monotherapy vs. conventional DAPT. In complex PCI patients, P2Y12 inhibitor monotherapy was associated with a lower risk of NACE than conventional DAPT [Odds ratio (OR) 0.76, 95% confidence interval (CI) 0.63-0.91, P = 0.003], whereas in non-complex PCI patients, P2Y12 inhibitor monotherapy was associated with a trend toward lowering the risk of NACE (OR 0.86, 95% CI 0.72-1.02, P = 0.09). This meta-analysis across randomized trials demonstrated that a strategy of short DAPT followed by P2Y12 inhibitor monotherapy reduces the risk of 1-year NACE in patients undergoing complex PCI.
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Affiliation(s)
- Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuki Matsuoka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Xi Z, Wang Y, Lu Q, Qiu H, Gao Y, Gao A, Gao R. Implementation of CYP2C19 genotyping and clinical outcomes following percutaneous coronary intervention in East Asian patients treated with oral P2Y 12 inhibitors. Thromb Res 2023; 228:85-93. [PMID: 37301117 DOI: 10.1016/j.thromres.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/25/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The CYP2C19 loss-of-function variants have significant impact on response to clopidogrel. The efficacy and safety of tailored antiplatelet therapy under the guidance of CYP2C19 genetic polymorphisms remains elusive for patients undergoing percutaneous coronary intervention (PCI). OBJECTIVES The aims of the present study were to investigate the impact of clinical implementation of CYP2C19 genotyping on the selection of oral P2Y12 inhibitor therapy following PCI, and to estimate the risk of adverse outcomes for patients with different genotype status treated with alternative or traditional P2Y12 inhibitor. METHODS Data from a single-center registry enrolling 41,090 consecutive PCI patients treated with dual antiplatelet therapy after PCI were analyzed. Risk of major adverse cardiovascular events (MACEs) and bleeding events within 12 months after PCI were compared across CYP2C19 genotype and antiplatelet therapy groups using Cox proportional hazards models. RESULTS CYP2C19 genotyping was successfully achieved for 9081 patients, of whom baseline characteristics significantly differed from non-genotyped patients. A higher proportion of genotyped patients were prescribed ticagrelor compared with non-genotyped patients (27.0 % vs. 15.5 %, P < 0.001). CYP2C19 metabolic status was an independent predictor for use of ticagrelor (P < 0.001). Ticagrelor was significantly associated with a lower risk of MACEs in poor metabolizers (adjusted hazard ratio 0.62, 95 % confidence interval 0.42 to 0.92, P = 0.017), but not in intermediate metabolizers or normal metabolizers. The interaction was not statistically significant (P for interaction = 0.252). CONCLUSIONS Genotype information on CYP2C19 metabolic status was associated with an increase in the use of potent antiplatelet therapy in PCI patients. Patients prescribed with clopidogrel has a higher risk of MACEs among poor metabolizers, which suggested the potential application of genotype-guided P2Y12 inhibitor selection for improving clinical outcomes.
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Affiliation(s)
- Ziwei Xi
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Cardio-Metabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Wang
- Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qianhong Lu
- Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong Qiu
- Department of Cardiology, Cardio-Metabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yanan Gao
- Department of Cardiology, Cardio-Metabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ang Gao
- Department of Cardiology, Cardio-Metabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- Department of Cardiology, Cardio-Metabolic Medicine Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiology, Coronary Artery Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Scudiero F, Canonico ME, Sanna GD, Dossi F, Silverio A, Galasso G, Esposito G, Porto I, Parodi G. Dual Antiplatelet Therapy with 3 rd Generation P2Y 12 Inhibitors in STEMI Patients: Impact of Body Mass Index on Loading Dose-Response. Cardiovasc Drugs Ther 2023; 37:695-703. [PMID: 35175499 DOI: 10.1007/s10557-022-07322-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This study aims to assess the association between body mass index (BMI) and platelet reactivity in STEMI patients treated with oral 3rd generation P2Y12 inhibitors. METHODS Overall, 429 STEMI patients were enrolled in this study. Patients were divided into two groups according to BMI (BMI < 25 vs ≥ 25 kg/m2). A propensity score matching (1:1) was performed to balance potential confounders in patient baseline characteristics. Platelet reactivity was assessed by VerifyNow at baseline and after 3rd generation P2Y12 inhibitor (ticagrelor or prasugrel) loading dose (LD). Blood samples were obtained at baseline (T0), 1 h (T1), 2 h (T2), 4-6 h (T3), and 8-12 h (T4) after the LD. High on-treatment platelet reactivity (HTPR) was defined as a platelet reactivity unit value ≥ 208 units. RESULTS After propensity score matching, patients with BMI ≥ 25 had similar values of baseline platelet reactivity, while they had higher level of platelet reactivity at 1 and 2 h after the LD and higher rate of HRPT. Furthermore, multivariate analysis demonstrated that BMI ≥ 25 was an independent predictor of HTPR at 2 h (OR 2.01, p = .009). Conversely, starting from 4 h after the LD, platelet reactivity values and HRPT rates were comparable among the two study groups. CONCLUSIONS A BMI ≥ 25 kg/m2 is associated with delayed pharmacodynamic response to oral 3rd generation P2Y12 inhibitor LD, and it is a strong predictor of HTPR in STEMI patients treated by dual antiplatelet therapy with ticagrelor or prasugrel.
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Affiliation(s)
- Fernando Scudiero
- Medical Sciences Departement, Cardiology Unit, ASST Bergamo Est, Bolognini Hospital, Seriate, BG, Italy
| | - Mario E Canonico
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Giuseppe D Sanna
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Filippo Dossi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
- Cardiology Unit, ASL4 Liguria, Ospedali del Tigullio, Polo Di Lavagna, GE, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Guido Parodi
- Cardiology Unit, ASL4 Liguria, Ospedali del Tigullio, Polo Di Lavagna, GE, Italy.
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Carlin S, Eikelboom J. Are P2Y12 inhibitors superior to aspirin for long-term secondary prevention of cardiovascular disease? Expert Rev Cardiovasc Ther 2023; 21:305-309. [PMID: 37010071 DOI: 10.1080/14779072.2023.2199155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/31/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Stephanie Carlin
- Thrombosis Service, Hamilton General Hospital, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - John Eikelboom
- Thrombosis Service, Hamilton General Hospital, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
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36
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Khalaji A, Behnoush AH, Peiman S. Aspirin and P2Y12 inhibitors in treating COVID-19. Eur J Intern Med 2023; 110:101-103. [PMID: 36464550 PMCID: PMC9682055 DOI: 10.1016/j.ejim.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Soheil Peiman
- Department of Internal Medicine, AdventHealth Orlando hospital, Orlando, FL, United States.
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Gragnano F, Valgimigli M, Calabrò P. [Debate on antiplatelet monotherapy: P2Y12 inhibitor monotherapy in patients with coronary artery disease]. G Ital Cardiol (Rome) 2023; 24:19S-20S. [PMID: 37158027 DOI: 10.1714/4035.40101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Felice Gragnano
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi della Campania Luigi Vanvitelli, Caserta - Divisione di Cardiologia, Dipartimento Cardio-Vascolare, AORN Sant'Anna e San Sebastiano, Caserta
| | - Marco Valgimigli
- Istituto CardioCentro Ticino e Università della Svizzera Italiana (USI), Lugano, Svizzera
| | - Paolo Calabrò
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi della Campania Luigi Vanvitelli, Caserta - Divisione di Cardiologia, Dipartimento Cardio-Vascolare, AORN Sant'Anna e San Sebastiano, Caserta
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Koshy AN, Giustino G, Sartori S, Hooda A, Feng Y, Snyder C, Dasgupta S, Kumar KR, Krishnamoorthy-Melarcode P, Sweeny J, Khera S, Serrao GW, Sharma R, Dangas G, Kini AS, Mehran R, Sharma SK. Ticagrelor or prasugrel versus clopidogrel in patients undergoing percutaneous coronary intervention for chronic coronary syndromes. EUROINTERVENTION 2023; 18:1244-1253. [PMID: 36660810 PMCID: PMC10018287 DOI: 10.4244/eij-d-22-00654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/09/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Potent P2Y12 inhibitors such as ticagrelor and prasugrel are superior to clopidogrel in acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI). Whether this benefit extends to a patient population with chronic coronary syndromes (CCS) is unclear. AIMS We sought to compare the safety and efficacy of prasugrel and ticagrelor versus clopidogrel in patients undergoing PCI for CCS. METHODS Consecutive patients undergoing PCI for CCS at a tertiary centre between 2014 and 2019 who were discharged on prasugrel or ticagrelor were compared with those on clopidogrel. The primary endpoint was the composite of death and myocardial infarction (MI), with secondary outcomes including rates of bleeding, stroke, and target vessel revascularisation at 1 year. RESULTS Overall, 11,508 patients were included in the study (ticagrelor/prasugrel n=2,860 [24.9%], clopidogrel n=8,648 [75.1%]) with an increasing frequency of potent P2Y12 inhibitor use over the study period (ptrend<0.001). Clopidogrel was used more frequently in patients with multimorbid risk factors, whereas anatomical or procedural complexity was associated with ticagrelor/prasugrel use (left main PCI, bifurcation PCI, number of lesions, rotational atherectomy). No difference in the incidence of death or MI was noted across the groups (ticagrelor/prasugrel vs clopidogrel: 2.7% vs 3.1%, adjusted hazard ratio [adjHR] 0.86, 95% confidence interval [CI]: 0.62-1.17; p=0.33) or secondary outcomes including bleeding (adjHR 0.75, 95% CI: 0.46-1.21; p=0.23) on propensity score stratification analysis. Additionally, no difference in the primary outcome was observed across subgroups, including those undergoing complex PCI. CONCLUSIONS Ticagrelor and prasugrel are increasingly used in patients with CCS undergoing PCI with similar 1-year efficacy and safety when compared to clopidogrel. Whether use of these agents can be beneficial in patients undergoing PCI for CCS with a high thrombotic and low bleeding risk warrants further study.
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Affiliation(s)
- Anoop N Koshy
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Cardiology, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amit Hooda
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Clayton Snyder
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shabitri Dasgupta
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kartik R Kumar
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Joseph Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sahil Khera
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raman Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annapoorna S Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Levens AD, den Haan MC, Jukema JW, Heringa M, van den Hout WB, Moes DJAR, Swen JJ. Feasibility of Community Pharmacist-Initiated and Point-of-Care CYP2C19 Genotype-Guided De-Escalation of Oral P2Y12 Inhibitors. Genes (Basel) 2023; 14:genes14030578. [PMID: 36980851 PMCID: PMC10048116 DOI: 10.3390/genes14030578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 03/02/2023] Open
Abstract
Tailoring antiplatelet therapy based on CYP2C19 pharmacogenetic (PGx) testing can improve cardiovascular outcomes and potentially reduce healthcare costs in patients on a P2Y12-inhibitor regime with prasugrel or ticagrelor. However, ubiquitous adoption—particularly in an outpatient setting—remains limited. We conducted a proof-of-concept study to evaluate the feasibility of CYP2C19-guided de-escalation of prasugrel/ticagrelor to clopidogrel through point-of-care (POC) PGx testing in the community pharmacy. Multiple feasibility outcomes were assessed. Overall, 144 patients underwent CYP2C19 PGx testing in 27 community pharmacies. Successful test results were obtained in 142 patients (98.6%). De-escalation to clopidogrel occurred in 19 patients (20%) out of 95 (67%) eligible for therapy de-escalation, which was mainly due to PGx testing not being included in cardiology guidelines. Out of the 119 patients (84%) and 14 pharmacists (100%) surveyed, 109 patients (92%) found the community pharmacy a suitable location for PGx testing, and the majority of pharmacists (86%) thought it has added value. Net costs due to PGx testing were estimated at €43 per patient, which could be reduced by earlier testing and could turn into savings if de-escalation would double to 40%. Although the observed de-escalation rate was low, POC CYP2C19-guided de-escalation to clopidogrel appears feasible in a community pharmacy setting.
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Affiliation(s)
- Amar D. Levens
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Melina C. den Haan
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Mette Heringa
- SIR Institute for Pharmacy Practice and Policy, 2331 JE Leiden, The Netherlands
| | - Wilbert B. van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Jesse J. Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Correspondence:
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40
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O'Malley K, Hwang YJ, Trost J, Feldman L. Things We Do for No Reason™: Routine pretreatment with a P2Y12 receptor inhibitor before invasive coronary angiography for patients with a non-ST elevation acute coronary syndrome. J Hosp Med 2023; 18:177-180. [PMID: 35920593 DOI: 10.1002/jhm.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Kevin O'Malley
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yoseob Joseph Hwang
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Trost
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leonard Feldman
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Kumar A, Lutsey PL, St Peter WL, Schommer JC, Van't Hof JR, Rajpurohit A, Farley JF. Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome: A Propensity Score-Matched Cohort Study. Clin Pharmacol Ther 2023; 113:401-411. [PMID: 36399019 PMCID: PMC9877194 DOI: 10.1002/cpt.2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
Comparative effectiveness evaluation of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared with clopidogrel after acute coronary syndrome (ACS) is limited in real-world US populations. The objective of this study was to evaluate cardiovascular events based on ticagrelor, prasugrel, and clopidogrel use in a real-world patient setting. This retrospective cohort study used the IBM MarketScan database (January 1, 2013, to December 31, 2018) to create three propensity score-matched pairs: ticagrelor vs. clopidogrel (N = 21,719), prasugrel vs. clopidogrel (N = 11,513), and prasugrel vs. ticagrelor (N = 11,065). The primary outcome was a composite of myocardial ischemia, unstable angina, stroke, and heart failure hospitalization. These groups were compared in a time-to-event analysis for the primary outcome at 30, 90, and 180 days following P2Y12 inhibitors initiation after percutaneous coronary intervention. Compared with clopidogrel, ticagrelor use suggested a 10% reduction in the primary outcome at 90 days (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). There were no differences for all other matched pairs or follow-up combinations. In the subgroup analysis of females, the results suggested a risk reduction of 27% for prasugrel at 30 days (HR: 0.73, 95% CI: 0.53-1.00) and 17% for ticagrelor at 90 days (HR: 0.83, 95% CI: 0.70-0.98) when compared with clopidogrel. Among patients treated with bare-metal stents, the results suggested that prasugrel vs. ticagrelor was associated with a 55% and 33% reduced risk for the primary outcome at 30 days and 180 days, respectively. With limited evidence in the United States comparing these drugs, this study helps inform clinicians when choosing P2Y12 inhibitors after ACS.
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Affiliation(s)
- Arun Kumar
- Department of Pharmacy Practice & Administrative SciencesJames L. Winkle College of Pharmacy, University of CincinnatiCincinnatiOhioUSA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthSchool of Public Health, University of MinnesotaMinneapolisMinnesotaUSA
| | - Wendy L. St Peter
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jon C. Schommer
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jeremy R. Van't Hof
- Cardiovascular Division and Lillehei Heart InstituteUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Abhijeet Rajpurohit
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Joel F. Farley
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Smits PC, Van Mieghem NM, Vlachojannis GJ. Pre-hospital treatment with crushed versus integral tablets of prasugrel in patients presenting with ST-Segment Elevation Myocardial Infarction-1-year follow-up results of the COMPARE CRUSH trial. Am Heart J 2022; 252:26-30. [PMID: 35671829 DOI: 10.1016/j.ahj.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/31/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
The present research letter reports the 1-year clinical outcomes of the randomized COMPARE CRUSH trial, which allocated STEMI patients at first medical contact in the ambulance to receive either crushed or integral tablets of prasugrel loading dose. This trial aimed to investigate whether early enhanced antiplatelet effect constituted by the crushed potent oral P2Y12 inhibitor prasugrel could lead to improved early myocardial reperfusion and clinical outcomes.
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Affiliation(s)
- Rosanne F Vogel
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel E Lemmert
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Dimitrios Alexopoulos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gilles Montalescot
- Sorbonne University, ACTION group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France
| | - Dominick J Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands.
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Rogers AL, Akhter SA. Platelet Function Testing-Based Timing of Urgent CABG Following Treatment with P2Y12 Inhibitors. Ann Thorac Surg 2022; 115:1331-1332. [PMID: 36115388 DOI: 10.1016/j.athoracsur.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Austin L Rogers
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute and Brody School of Medicine at East Carolina University, 115 Heart Dr, Rm 3211, Greenville, NC 27834
| | - Shahab A Akhter
- Division of Cardiac Surgery, Department of Cardiovascular Sciences, East Carolina Heart Institute and Brody School of Medicine at East Carolina University, 115 Heart Dr, Rm 3211, Greenville, NC 27834.
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Omerovic E, Erlinge D, Koul S, Frobert O, Andersson J, Ponten J, Björklund F, Kastberg R, Petzold M, Ljungman C, Bolin K, Redfors B. Rationale and design of switch Swedeheart: A registry-based, stepped-wedge, cluster-randomized, open-label multicenter trial to compare prasugrel and ticagrelor for treatment of patients with acute coronary syndrome. Am Heart J 2022; 251:70-77. [PMID: 35644221 DOI: 10.1016/j.ahj.2022.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND European treatment guidelines recommend prasugrel over ticagrelor for treating patients with non-ST-elevation acute coronary syndrome (ACS), prompting several Swedish administrative regions to transition from ticagrelor to prasugrel as the preferred treatment for patients with ACS. We aim to systematically evaluate this transition to determine the relative efficacy of prasugrel versus ticagrelor in a real-world cohort of patients with ACS. STUDY DESIGN AND OBJECTIVES The SWITCH SWEDEHEART trial is a prospective, multicenter, open-label, cross-sectional, stepped-wedge cluster-randomized clinical trial, in which administrative regions in Sweden will constitute the clusters. At the start of the study, all clusters will use ticagrelor as the P2Y12 inhibitor drug of choice for ACS. The order in which the clusters will implement the transition from ticagrelor to prasugrel will be randomly assigned. Every 9 months, 1 cluster will switch from ticagrelor to prasugrel as the P2Y12 inhibitor of choice for patients with ACS. The primary endpoint is the composite 1-year rate of the death, stroke, or myocardial infarction. CONCLUSIONS The SWITCH SWEDEHEART study will provide an extensive randomized comparison between ticagrelor and prasugrel. Novel therapies are frequently costly and supported by evidence from few or small studies, and systematic evaluation after the introduction is rare. This study will establish an important standard for introducing and evaluating the effects of health care changes within our societies.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Ole Frobert
- Department of Cardiology, Faculty of Health, Örebro University Hospital, Örebro, Sweden; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jonas Andersson
- Department of Cardiology, Umeå University Hospital, Umeå, Sweden
| | - Johan Ponten
- Department of Cardiology, Hallands hospital Halmstad, Halmstad, Sweden
| | | | - Robert Kastberg
- Department of Cardiology, Östersund Hospital, Östersund, Sweden
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Sweden
| | - Charlotta Ljungman
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Bolin
- Department of Economics, Centre for Health Economics, University of Gothenburg, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Panzer B, Wadowski PP, Huber K, Panzer S, Gremmel T. Protease-activated receptor-mediated platelet aggregation in patients with type 2 diabetes on potent P2Y 12 inhibitors. Diabet Med 2022; 39:e14868. [PMID: 35514270 PMCID: PMC9546030 DOI: 10.1111/dme.14868] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/19/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiplatelet therapy is a cornerstone in the secondary prevention of ischemic events following percutaneous coronary intervention (PCI). The new P2Y12 receptor inhibitors prasugrel and ticagrelor have been shown to improve patients' outcomes. Whether or not these drugs have equal efficacy in individuals with or without diabetes is disputed. Furthermore, platelets can be activated by thrombin, which is, at least in part, independent of P2Y12 -mediated platelet activation. Protease-activated receptor (PAR)-1 and -4 are thrombin receptors on human platelets. We sought to compare the in vitro efficacy of prasugrel (n = 121) and ticagrelor (n = 99) to inhibit PAR-mediated platelet aggregation in individuals with type 2 diabetes (prasugrel n = 26, ticagrelor n = 29). MATERIALS AND METHODS We compared P2Y12 -, PAR-1- and PAR-4-mediated platelet aggregation as assessed by multiple electrode platelet aggregometry between prasugrel- and ticagrelor-treated patients without and with type 2 diabetes who underwent acute PCI. RESULTS Overall, there were no differences of P2Y12 -, PAR-1- and PAR-4-mediated platelet aggregation between prasugrel- and ticagrelor-treated patients. However, both drugs inhibited P2Y12 -mediated platelet aggregation stronger, and thereby to a similar extent in patients with type 2 diabetes than in those without diabetes. There was no correlation between either P2Y12 -, or PAR-1- or PAR-4-mediated platelet aggregation and levels of HbA1c or the body mass index (BMI). However, we observed patients with high residual platelet reactivity in response to PAR-1 and PAR-4 stimulation in all cohorts. CONCLUSION Prasugrel and ticagrelor inhibit P2Y12 - and PAR-mediated platelet aggregation in individuals with diabetes to a similar extent, irrespective of HbA1c levels and BMI.
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Affiliation(s)
- Benjamin Panzer
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
- Sigmund Freud University, Medical SchoolViennaAustria
| | | | - Kurt Huber
- Sigmund Freud University, Medical SchoolViennaAustria
- 3rd Department of MedicineCardiology and Intensive Care Medicine, Wilhelminen HospitalViennaAustria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion MedicineMedical University of ViennaViennaAustria
| | - Thomas Gremmel
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
- Institute of Antithrombotic Therapy in Cardiovascular DiseaseKarl Landsteiner SocietySt. PöltenAustria
- Department of Internal Medicine ICardiology and Intensive Care Medicine, Landesklinikum Mistelbach‐GänserndorfMistelbachAustria
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Patlolla SH, Kandlakunta H, Kuchkuntla AR, West CP, Murad MH, Wang Z, Kochar A, Rab ST, Gersh BJ, Holmes DR, Zhao DX, Vallabhajosyula S. Newer P2Y 12 Inhibitors vs Clopidogrel in Acute Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock: A Systematic Review and Meta-analysis. Mayo Clin Proc 2022; 97:1074-1085. [PMID: 35662424 DOI: 10.1016/j.mayocp.2022.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/18/2022] [Accepted: 02/15/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y12 inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS). PATIENTS AND METHODS MEDLINE, EMBASE, and the Cochrane Library were queried systematically from inception to January 2021 for comparative studies of adults (≥18 years) with AMI-CA/CS receiving DAPT with newer P2Y12 inhibitors as opposed to clopidogrel. We compared outcomes (30-day or in-hospital and 1-year all-cause mortality, major bleeding, and definite stent thrombosis) of newer P2Y12 inhibitors and clopidogrel in patients with AMI-CA/CS. RESULTS Eight studies (1 randomized trial and 7 cohort studies) comprising 1100 patients (695 [63.2%] receiving clopidogrel and 405 [36.8%] receiving ticagrelor or prasugrel) were included. The population was mostly male (68.5%-86.7%). Risk of bias was low for these studies, with between-study heterogeneity and subgroup differences not statistically significant. Compared with the clopidogrel cohort, the newer P2Y12 cohort had lower rates of early mortality (odds ratio [OR], 0.60; 95% CI, 0.45 to 0.81; P=.001) (7 studies) and 1-year mortality (OR, 0.51; 95% CI, 0.36 to 0.71; P<.001) (3 studies). We did not find a significant difference in major bleeding (OR, 1.21; 95% CI, 0.71 to 2.06; P=.48) (6 studies) or definite stent thrombosis (OR, 2.01; 95% CI, 0.63 to 6.45; P=.24) (7 studies). CONCLUSION In patients with AMI-CA/CS receiving DAPT, compared with clopidogrel, newer P2Y12 inhibitors were associated with lower rates of early and 1-year mortality. Data on major bleeding and stent thrombosis were inconclusive.
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Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Harika Kandlakunta
- Department of Medicine, Staten Island University Hospital, Staten Island, NY
| | | | - Colin P West
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ajar Kochar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - S Tanveer Rab
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
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Tao L, Ren S, Zhang L, Liu W, Zhao Y, Chen C, Mao X, Chen Z, Gu X. A Review of the Role of the Antiplatelet Drug Ticagrelor in the Management of Acute Coronary Syndrome, Acute Thrombotic Disease, and Other Diseases. Med Sci Monit 2022; 28:e935664. [PMID: 35570383 PMCID: PMC9121774 DOI: 10.12659/msm.935664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/09/2022] [Indexed: 11/20/2022] Open
Abstract
P2Y12 inhibitors, including aspirin, are key components of dual-antiplatelet therapy (DAPT), which is the optimal therapeutic strategy for preventing arterial thrombosis in patients with acute coronary syndromes (ACS) who underwent stent implantation. Ticagrelor is a cyclopentyl-triazole pyrimidine antiplatelet drug that was the first reversible oral P2Y12 receptor antagonist. Compared with clopidogrel, ticagrelor exerts a faster onset and offset of function by reversible and selective inhibition of platelet aggregation in ACS patients, including those with coronary artery blood revascularization. Despite improvement in stent materials, stent thrombosis (ST) due to high on-treatment platelet reactivity (HPR) to clopidogrel continues to occur. In addition to antiplatelet aggregation, ticagrelor displays pleiotropic cardioprotective effects, including improving coronary blood flow, reducing myocardial necrosis after an ischemic event, and anti-inflammatory effects. The benefits of ticagrelor over clopidogrel were consistent in the PLATO results, with lower incidence of the primary endpoint. Also, in 2020, the findings from the phase 3 THALES trial (NCT03354429) showed that aspirin combined with 90 mg of ticagrelor significantly reduced the rates of stroke and death compared with aspirin alone in patients with AIS or TIA. Here, we review recent research on the superiority of ticagrelor over clopidogrel, discuss the pharmacological mechanism, and present future perspectives. This review aims to present the roles of ticagrelor in the management of acute coronary syndrome, acute thrombotic disease, and other diseases.
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Hinwood M, Nyberg J, Leigh L, Gustavsson S, Attia J, Oldmeadow C, Ilicic M, Linden T, Åberg ND, Levi C, Spratt N, Carey LM, Pollack M, Johnson SJ, Kuhn GH, Walker FR, Nilsson M. Do P2Y12 receptor inhibitors prescribed poststroke modify the risk of cognitive disorder or dementia? Protocol for a target trial using multiple national Swedish registries. BMJ Open 2022; 12:e058244. [PMID: 35534077 PMCID: PMC9086614 DOI: 10.1136/bmjopen-2021-058244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The target of a class of antiplatelet medicines, P2Y12R inhibitors, exists both on platelets and on brain immune cells (microglia). This protocol aims to describe a causal (based on a counterfactual model) approach for analysing whether P2Y12R inhibitors prescribed for secondary prevention poststroke may increase the risk of cognitive disorder or dementia via their actions on microglia, using real-world evidence. METHODS AND ANALYSIS This will be a cohort study nested within the Swedish National Health and Medical Registers, including all people with incident stroke from 2006 to 2016. We developed directed acyclic graphs to operationalise the causal research question considering potential time-independent and time-dependent confounding, using input from several experts. We developed a study protocol following the components of the target trial approach described by Hernan et al and describe the data structure that would be required in order to make a causal inference. We also describe the statistical approach required to derive the causal estimand associated with this important clinical question; that is, a time-to-event analysis for the development of cognitive disorder or dementia at 1, 2 and 5-year follow-up, based on approaches for competing events to account for the risk of all-cause mortality. Causal effect estimates and the precision in these estimates will be quantified. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of the University of Gothenburg and Confidentiality Clearance at Statistics Sweden with Dnr 937-18, and an approved addendum with Dnr 2019-0157. The analysis and interpretation of the results will be heavily reliant on the structure, quality and potential for bias of the databases used. When we implement the protocol, we will consider and document any biases specific to the dataset and conduct appropriate sensitivity analyses. Findings will be disseminated to local stakeholders via conferences, and published in appropriate scientific journals.
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Affiliation(s)
- Madeleine Hinwood
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Jenny Nyberg
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
| | - Lucy Leigh
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Sara Gustavsson
- Department of Forensic Genetics, Forensic Toxicology National Board of Forensic Medicine, Linköping, Sweden
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christopher Oldmeadow
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Marina Ilicic
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Thomas Linden
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Neurorehabilitation and Recovery, Florey Neuroscience Institutes, Parkville, Victoria, Australia
| | - N David Åberg
- Department of Internal Medicine and Clinical Nutrition, University of Gothenburg, Goteborg, Sweden
- Department of Acute Medicine and Geriatrics, Sahlgrenska University Hospital, Goteborg, Region Västra Götaland, Sweden
| | - Chris Levi
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Neil Spratt
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, New South Wales, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Leeanne M Carey
- Neurorehabilitation and Recovery, Florey Neuroscience Institutes, Parkville, Victoria, Australia
- School of Allied Health, Human Services and Sport, La Trobe University - Melbourne Campus, Melbourne, Victoria, Australia
| | - Michael Pollack
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Sarah J Johnson
- School of Engineering, College of Engineering, Science and Environment, The University of Newcastle, Callaghan, New South Wales, Australia
- Center for Human and Health Sciences, Centre for Rehab Innovations, Callaghan, New South Wales, Australia
| | - Georg Hans Kuhn
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Institute for Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frederick R Walker
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, New South Wales, Australia
- Center for Human and Health Sciences, Centre for Rehab Innovations, Callaghan, New South Wales, Australia
| | - Michael Nilsson
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Center for Human and Health Sciences, Centre for Rehab Innovations, Callaghan, New South Wales, Australia
- LKC School of Medicine, Nanyang Technological University, Singapore
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Abdelazeem B, Shehata J, Abbas KS, El-Shahat NA, Baral N, Adhikari G, Khan H, Hassan M. De-escalation from Prasugrel or Ticagrelor to Clopidogrel in Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention: An Updated Meta-analysis of Randomized Clinical Trials. Am J Cardiovasc Drugs 2022; 22:287-298. [PMID: 34651261 DOI: 10.1007/s40256-021-00504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION We aimed to evaluate the clinical benefits of a de-escalation strategy from prasugrel or ticagrelor to clopidogrel versus continuation of prasugrel or ticagrelor along with aspirin in both strategies for patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI), and to analyze the effect of the recently published randomized clinical trial (RCT) by Park et al., which included the largest sample size ever and the largest switched number of patients, on current guidelines and practices. DATA SOURCES The PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar databases were searched systematically from inception to May 2021 by using the search terms ('de-escalation' OR 'switching') AND ('antiplatelet' OR 'clopidogrel' OR 'ticagrelor' OR 'prasugrel') AND ('percutaneous coronary intervention' OR 'PCI'' OR 'Acute coronary syndrome' OR 'ACS'). STUDY SELECTION AND DATA EXTRACTION We included RCTs that reported the primary outcomes, i.e. net clinical benefits and Bleeding Academic Research Consortium (BARC) type 2 or higher bleeding. A combination of both ischemic and bleeding events was defined as a net clinical benefit. DATA SYNTHESIS A total of four RCTs were included, with 5952 patients. A random-effects meta-analysis revealed that a de-escalation strategy was associated with lower ischemic and bleeding events (net clinical benefits; risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.85; p = 0.003), and lower BARC type 2 or higher bleeding (RR 0.51, 95% CI 0.29-0.91; p = 0.02) when compared with a continuation strategy. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The current guidelines recommend potent P2Y12 prasugrel or ticagrelor for 12 months despite their association with a high risk of bleeding. Our meta-analysis updates cardiologists, providing them with the best available evidence in managing patients with ACS who underwent PCI. CONCLUSION Among patients with ACS treated with PCI, a de-escalation strategy (prasugrel or ticagrelor to clopidogrel) is associated with lower ischemic and bleeding events (net clinical benefits) and lower BARC type 2 or higher bleeding; however, due to the limited number of included studies, further high-quality studies are needed to establish the clinical efficacy of the de-escalation strategy.
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Affiliation(s)
- Basel Abdelazeem
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA.
| | | | | | | | - Nischit Baral
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Govinda Adhikari
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Hafiz Khan
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Mustafa Hassan
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
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Bradbury CA, Lawler PR, Stanworth SJ, McVerry BJ, McQuilten Z, Higgins AM, Mouncey PR, Al-Beidh F, Rowan KM, Berry LR, Lorenzi E, Zarychanski R, Arabi YM, Annane D, Beane A, van Bentum-Puijk W, Bhimani Z, Bihari S, Bonten MJM, Brunkhorst FM, Buzgau A, Buxton M, Carrier M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Fitzgerald M, Girard TD, Goligher EC, Goossens H, Haniffa R, Hills T, Huang DT, Horvat CM, Hunt BJ, Ichihara N, Lamontagne F, Leavis HL, Linstrum KM, Litton E, Marshall JC, McAuley DF, McGlothlin A, McGuinness SP, Middeldorp S, Montgomery SK, Morpeth SC, Murthy S, Neal MD, Nichol AD, Parke RL, Parker JC, Reyes LF, Saito H, Santos MS, Saunders CT, Serpa-Neto A, Seymour CW, Shankar-Hari M, Singh V, Tolppa T, Turgeon AF, Turner AM, van de Veerdonk FL, Green C, Lewis RJ, Angus DC, McArthur CJ, Berry S, Derde LPG, Webb SA, Gordon AC. Effect of Antiplatelet Therapy on Survival and Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2022; 327:1247-1259. [PMID: 35315874 PMCID: PMC8941448 DOI: 10.1001/jama.2022.2910] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The efficacy of antiplatelet therapy in critically ill patients with COVID-19 is uncertain. Objective To determine whether antiplatelet therapy improves outcomes for critically ill adults with COVID-19. Design, Setting, and Participants In an ongoing adaptive platform trial (REMAP-CAP) testing multiple interventions within multiple therapeutic domains, 1557 critically ill adult patients with COVID-19 were enrolled between October 30, 2020, and June 23, 2021, from 105 sites in 8 countries and followed up for 90 days (final follow-up date: July 26, 2021). Interventions Patients were randomized to receive either open-label aspirin (n = 565), a P2Y12 inhibitor (n = 455), or no antiplatelet therapy (control; n = 529). Interventions were continued in the hospital for a maximum of 14 days and were in addition to anticoagulation thromboprophylaxis. Main Outcomes and Measures The primary end point was organ support-free days (days alive and free of intensive care unit-based respiratory or cardiovascular organ support) within 21 days, ranging from -1 for any death in hospital (censored at 90 days) to 22 for survivors with no organ support. There were 13 secondary outcomes, including survival to discharge and major bleeding to 14 days. The primary analysis was a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented improved survival, more organ support-free days, or both. Efficacy was defined as greater than 99% posterior probability of an OR greater than 1. Futility was defined as greater than 95% posterior probability of an OR less than 1.2 vs control. Intervention equivalence was defined as greater than 90% probability that the OR (compared with each other) was between 1/1.2 and 1.2 for 2 noncontrol interventions. Results The aspirin and P2Y12 inhibitor groups met the predefined criteria for equivalence at an adaptive analysis and were statistically pooled for further analysis. Enrollment was discontinued after the prespecified criterion for futility was met for the pooled antiplatelet group compared with control. Among the 1557 critically ill patients randomized, 8 patients withdrew consent and 1549 completed the trial (median age, 57 years; 521 [33.6%] female). The median for organ support-free days was 7 (IQR, -1 to 16) in both the antiplatelet and control groups (median-adjusted OR, 1.02 [95% credible interval {CrI}, 0.86-1.23]; 95.7% posterior probability of futility). The proportions of patients surviving to hospital discharge were 71.5% (723/1011) and 67.9% (354/521) in the antiplatelet and control groups, respectively (median-adjusted OR, 1.27 [95% CrI, 0.99-1.62]; adjusted absolute difference, 5% [95% CrI, -0.2% to 9.5%]; 97% posterior probability of efficacy). Among survivors, the median for organ support-free days was 14 in both groups. Major bleeding occurred in 2.1% and 0.4% of patients in the antiplatelet and control groups (adjusted OR, 2.97 [95% CrI, 1.23-8.28]; adjusted absolute risk increase, 0.8% [95% CrI, 0.1%-2.7%]; 99.4% probability of harm). Conclusions and Relevance Among critically ill patients with COVID-19, treatment with an antiplatelet agent, compared with no antiplatelet agent, had a low likelihood of providing improvement in the number of organ support-free days within 21 days. Trial Registration ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- University of Oxford, Oxford, England
- NHS Blood and Transplant, Oxford, England
| | | | - Zoe McQuilten
- Monash University, Melbourne, Victoria, Australia
- Monash Health, Melbourne, Victoria, Australia
| | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre (ICNARC), London, England
| | | | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), London, England
| | | | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY-Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | - Zahra Bhimani
- St Michael's Hospital Unity Health, Toronto, Ontario, Canada
| | - Shailesh Bihari
- Flinders University, Bedford Park, South Australia, Australia
| | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Los Angeles, California
| | - Marc Carrier
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Allen C Cheng
- Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Matthew Cove
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | | | | | - Ewan C Goligher
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | | | - Helen L Leavis
- University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Edward Litton
- Fiona Stanley Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Australia
| | - John C Marshall
- St Michael's Hospital Unity Health, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Victoria, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | | | | | | | - Alistair D Nichol
- Monash University, Melbourne, Victoria, Australia
- University College Dublin, Dublin, Ireland
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | - Ary Serpa-Neto
- Monash University, Melbourne, Victoria, Australia
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Manu Shankar-Hari
- King's College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, London, England
| | | | - Timo Tolppa
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - Alexis F Turgeon
- Université Laval, Québec City, Québec, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Québec, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | - Steve A Webb
- Monash University, Melbourne, Victoria, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Imperial College London, London, England
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, England
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