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Stouffer GA, Friede KA, Rossi JS. Pretreating With P2Y 12 Inhibitors in STEMI: Does It Make Any Difference? JACC Cardiovasc Interv 2024; 17:29-31. [PMID: 38199750 DOI: 10.1016/j.jcin.2023.11.017] [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: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024]
Affiliation(s)
- George A Stouffer
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA; McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Kevin A Friede
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA; McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joseph S Rossi
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA
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Kulick N, Folk D, Friede KA, Stouffer GA. Association of Coronary Flow With Response to Intracoronary Tenecteplase in Patients With ST Elevation Myocardial Infarction With Thrombotic Complications During Primary Percutaneous Coronary Intervention. Am J Cardiol 2023; 206:1-3. [PMID: 37677876 DOI: 10.1016/j.amjcard.2023.08.091] [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: 07/05/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Affiliation(s)
- Natasha Kulick
- Division of Cardiology; The McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - Destiny Folk
- Emergency Medicine, Atrium Health, Charlotte, North Carolina
| | - Kevin A Friede
- Division of Cardiology; The McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - George A Stouffer
- Division of Cardiology; The McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina.
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Chanfreau-Coffinier C, Friede KA, Plomondon ME, Lee KM, Lu Z, Lynch JA, DuVall SL, Vassy JL, Waldo SW, Cleator JH, Maddox TM, Rader DJ, Assimes TL, Damrauer SM, Tsao PS, Chang KM, Voora D, Giri J, Tuteja S. CYP2C19 Polymorphisms and Clinical Outcomes Following Percutaneous Coronary Intervention (PCI) in the Million Veterans Program. medRxiv 2023:2023.10.25.23297578. [PMID: 37961335 PMCID: PMC10635203 DOI: 10.1101/2023.10.25.23297578] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Background CYP2C19 loss-of-function (LOF) alleles decrease the antiplatelet effect of clopidogrel following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). The impact of genotype in stable ischemic heart disease (SIHD) is unclear. Objectives Determine the association of CYP2C19 genotype with major adverse cardiac events (MACE) after PCI for ACS or SIHD. Methods Million Veterans Program (MVP) participants age <65 years with a PCI documented in the VA Clinical Assessment, Reporting and Tracking (CART) Program between 1/1/2009 to 9/30/2017, treated with clopidogrel were included. Time to MACE defined as the composite of all-cause death, stroke or myocardial infarction within 12 months following PCI. Results Among 4,461 Veterans (mean age 59.1 ± 5.1 years, 18% Black); 44% had ACS, 56% had SIHD and 29% carried a CYP2C19 LOF allele. 301 patients (6.7%) experienced MACE while being treated with clopidogrel, 155 (7.9%) in the ACS group and 146 (5.9%) in the SIHD group. Overall, MACE was not significantly different between LOF carriers vs. noncarriers (adjusted hazard ratio [HR] 1.18, confidence interval [95%CI] 0.97-1.45, p=0.096). Among patients presenting with ACS, MACE risk in LOF carriers versus non-carriers was numerically higher (HR 1.30, 95%CI 0.98-1.73, p=0.067). There was no difference in MACE risk in patients with SIHD (HR 1.09, 95%CI 0.82-1.44; p=0.565). Conclusions CYP2C19 LOF carriers presenting with ACS treated with clopidogrel following PCI experienced a numerically greater elevated risk of MACE events. CYP2C19 LOF genotype is not associated with MACE among patients presenting with SIHD.
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Affiliation(s)
| | - Kevin A. Friede
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Mary E. Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
| | - Kyung Min Lee
- VA Salt Lake City Heath Care System, Salt Lake City, UT
| | - Zhenyu Lu
- VA Salt Lake City Heath Care System, Salt Lake City, UT
| | - Julie A. Lynch
- VA Salt Lake City Heath Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Scott L. DuVall
- VA Salt Lake City Heath Care System, Salt Lake City, UT
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jason L. Vassy
- VA Boston Healthcare System, Harvard Medical School, and Brigham and Women’s Hospital, Boston, MA
| | - Stephen W. Waldo
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC
- Rocky Mountain Regional VA Medical Center and University of Colorado School of Medicine, Aurora, CO
| | | | - Thomas M. Maddox
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Daniel J. Rader
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Scott M. Damrauer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Philip S. Tsao
- VA Palo Alto Healthcare System and Stanford University, Palo Alto, CA
| | - Kyong-Mi Chang
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Deepak Voora
- Durham VA Healthcare System and Duke University, Durham, NC
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Oni-Orisan A, Tuteja S, Hoffecker G, Smith DM, Castrichini M, Crews KR, Murphy WA, Nguyen NHK, Huang Y, Lteif C, Friede KA, Tantisira K, Aminkeng F, Voora D, Cavallari LH, Whirl-Carrillo M, Duarte JD, Luzum JA. An Introductory Tutorial on Cardiovascular Pharmacogenetics for Healthcare Providers. Clin Pharmacol Ther 2023; 114:275-287. [PMID: 37303270 PMCID: PMC10406163 DOI: 10.1002/cpt.2957] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/17/2023] [Indexed: 06/13/2023]
Abstract
Pharmacogenetics can improve clinical outcomes by reducing adverse drug effects and enhancing therapeutic efficacy for commonly used drugs that treat a wide range of cardiovascular diseases. One of the major barriers to the clinical implementation of cardiovascular pharmacogenetics is limited education on this field for current healthcare providers and students. The abundance of pharmacogenetic literature underscores its promise, but it can also be challenging to learn such a wealth of information. Moreover, current clinical recommendations for cardiovascular pharmacogenetics can be confusing because they are outdated, incomplete, or inconsistent. A myriad of misconceptions about the promise and feasibility of cardiovascular pharmacogenetics among healthcare providers also has halted clinical implementation. Therefore, the main goal of this tutorial is to provide introductory education on the use of cardiovascular pharmacogenetics in clinical practice. The target audience is any healthcare provider (or student) with patients that use or have indications for cardiovascular drugs. This tutorial is organized into the following 6 steps: (1) understand basic concepts in pharmacogenetics; (2) gain foundational knowledge of cardiovascular pharmacogenetics; (3) learn the different organizations that release cardiovascular pharmacogenetic guidelines and recommendations; (4) know the current cardiovascular drugs/drug classes to focus on clinically and the supporting evidence; (5) discuss an example patient case of cardiovascular pharmacogenetics; and (6) develop an appreciation for emerging areas in cardiovascular pharmacogenetics. Ultimately, improved education among healthcare providers on cardiovascular pharmacogenetics will lead to a greater understanding for its potential in improving outcomes for a leading cause of morbidity and mortality.
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Affiliation(s)
- Akinyemi Oni-Orisan
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Sony Tuteja
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Glenda Hoffecker
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - D. Max Smith
- MedStar Health, Columbia, Maryland, USA
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Matteo Castrichini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristine R. Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - William A. Murphy
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nam H. K. Nguyen
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Yimei Huang
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Christelle Lteif
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kevin A. Friede
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kelan Tantisira
- Division of Respiratory Medicine, Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Folefac Aminkeng
- Departments of Medicine and Biomedical Informatics (DBMI), Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
- Centre for Precision Health (CPH), National University Health System (NUHS), Singapore City, Singapore
| | - Deepak Voora
- Precision Medicine Program, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Jasmine A. Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Center for Individualized and Genomic Medicine Research, Henry Ford Health System, Detroit, Michigan, USA
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Dong OM, Friede KA, Chanfreau-Coffinier C, Voora D. Cost-effectiveness of CYP2C19-guided P2Y12 inhibitors in Veterans undergoing percutaneous coronary intervention for acute coronary syndromes. Eur Heart J Qual Care Clin Outcomes 2023; 9:249-257. [PMID: 35652783 PMCID: PMC10272926 DOI: 10.1093/ehjqcco/qcac031] [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] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/04/2022] [Accepted: 05/30/2022] [Indexed: 05/17/2023]
Abstract
AIMS CYP2C19-guided P2Y12 inhibitor selection can reduce cardiovascular (CV) events and bleeding in patients with acute coronary syndromes (ACSs) post-percutaneous coronary intervention (PCI). The 12-month cost-effectiveness of CYP2C19-guided P2Y12 inhibitor selection for Veterans post-ACS/PCI was evaluated from the Veterans Health Administration's (VHA) perspective. METHODS AND RESULTS Using average annualized PCI volumes and P2Y12 inhibitor use from VA data, a decision-analytic model simulated CYP2C19 testing vs. no testing outcomes in 2800 hypothetical Veterans receiving PY212 inhibitor for 12 months post-ACS/PCI (74% clopidogrel, 5% prasugrel, and 21% ticagrelor use at baseline without testing). CYP2C19 loss-of-function (LOF) carrier prevalence was 28%. Model inputs were from studies (bleeding/ischaemic events, CYP2C19-guided therapy effect, health state utilities, CYP2C19 LOF carrier prevalence) and VHA administrative data (costs of events, drugs, CYP2C19 testing; PCI volumes, and P2Y12 inhibitor prescriptions). The primary outcome was cost (2020 US${\$}$) per quality-adjusted life year (QALY) gained. Base-case scenarios, probabilistic sensitivity analyses, and scenario analyses were completed. CYP2C19-guided therapy resulted in 496 (24%) escalations (clopidogrel to prasugrel/ticagrelor) and 465 (65%) de-escalations (prasugrel/ticagrelor to clopidogrel). CYP2C19 testing averted 1 stroke, 27 myocardial infarctions, 8 CV-related deaths, and caused 3 bleeds. CYP2C19 testing (vs. no testing) was dominant in the base-case scenario (0.0027 QALYs gained, ${\$}$527 saved/person) and in 97.1% of simulations, making it cost-effective and high-value. In scenario analyses, de-escalation in conjunction with escalation is required for CYP2C19 testing to be cost-effective and high-value. CONCLUSION In Veterans post-ACS/PCI, CYP2C19-guided P2Y12 inhibitor selection can improve CV outcomes and lower costs for the VHA within 12 months of implementation.
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Affiliation(s)
- Olivia M Dong
- Duke Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University School of Medicine, 101 Science Dr. CIEMAS Building, Durham, NC 27708, USA
- Durham VA Health Care System, 508 Fulton St, Durham, NC 27705, USA
| | - Kevin A Friede
- Duke Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University School of Medicine, 101 Science Dr. CIEMAS Building, Durham, NC 27708, USA
| | - Catherine Chanfreau-Coffinier
- VA Informatics and Computing Infrastructure (VINCI), Salt Lake City VA Health Care System, 500 Foothill Blvd, Salt Lake City, UT 84148, USA
| | - Deepak Voora
- Duke Center for Applied Genomics & Precision Medicine, Department of Medicine, Duke University School of Medicine, 101 Science Dr. CIEMAS Building, Durham, NC 27708, USA
- Durham VA Health Care System, 508 Fulton St, Durham, NC 27705, USA
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Kulick N, Friede KA, Stouffer GA. Safety and efficacy of intracoronary thrombolytic agents during primary percutaneous coronary intervention for STEMI. Expert Rev Cardiovasc Ther 2023; 21:165-175. [PMID: 36825458 DOI: 10.1080/14779072.2023.2184353] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Large thrombus burden in patients with ST elevation myocardial infarction (STEMI) is associated with higher rates of distal embolization, no-reflow phenomenon, abrupt closure, stent thrombosis, major adverse cardiovascular events (MACE), and mortality. Intracoronary (IC) thrombolytic agents are theoretically attractive as an adjunct to primary percutaneous coronary intervention (PPCI) as they activate endogenous fibrinolysis which results in degradation of the cross-linked fibrin matrix in coronary thrombus. AREAS COVERED We reviewed published studies reporting on intraprocedural anti-thrombus strategies used during PPCI including randomized controlled trials and observational studies. EXPERT OPINION Published studies are limited by small sample size and heterogeneity due to variation in indication, inclusion criteria, thrombolytic agent, dose, delivery mechanisms, antiplatelet and anticoagulant regimen, timing in regard to reperfusion, PCI techniques, and endpoints. Despite these limitations, data are consistent that IC administration of thrombolytic agents at low doses is associated with low rates of bleeding and vascular complications. While there is currently no compelling data demonstrating a benefit to the routine use of IC thrombolytic therapy in patients with STEMI, there is suggestive data that IC thrombolysis may have benefit in selected patients.
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Affiliation(s)
- Natasha Kulick
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Kevin A Friede
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology and the McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
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Friede KA, Myers RA, Gales J, Zhbannikov I, Ortel TL, Shah SH, Kraus WE, Ginsburg GS, Voora D. OUP accepted manuscript. Cardiovasc Res 2022; 119:551-560. [PMID: 35576481 DOI: 10.1093/cvr/cvac079] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 04/10/2022] [Accepted: 04/25/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Gene expression biosignatures may hold promise to individualize antiplatelet therapy in conjunction with current guidelines and risk scores. The Aspirin Response Signature (ARS) score is comprised of a weighted sum of correlated, pro-thrombotic gene transcripts measured in whole blood. In prior work where volunteers were exposed to aspirin 325 mg daily, higher ARS score was associated with lower platelet function; separately, in a clinical cohort of patients, higher ARS scores were associated with increased risk of adverse cardiovascular events. To better understand this apparent paradox, we measured ARS gene expression and score in volunteers to determine aspirin dose-response and ticagrelor relationships with ARS score and separately in patients to assess whether ARS is associated with incident bleeding. METHODS AND RESULTS Blood samples were collected from volunteers (N = 188) who were exposed to 4 weeks of daily aspirin 81 mg, daily aspirin 325 mg, and/or twice-daily ticagrelor 90 mg. ARS scores were calculated from whole blood RNA qPCR, and platelet function and protein expression were assessed in platelet-rich plasma. In mixed linear regression models, aspirin 81 mg exposure was not associated with changes in ARS gene expression or score. Aspirin 325 mg exposure resulted in a 6.0% increase in ARS gene expression (P = 7.5 × 10-9 vs. baseline, P = 2.1 × 10-4 vs. aspirin 81 mg) and an increase in expression of platelet proteins corresponding to ARS genes. Ticagrelor exposure resulted in a 30.7% increase in ARS gene expression (P < 1 × 10-10 vs. baseline and each aspirin dose) and ARS score (P = 7.0 × 10-7 vs. baseline, P = 3.6 × 10-6 and 5.59 × 10-4 vs. aspirin 81 and 325 mg, respectively). Increases in ARS gene expression or score were associated with the magnitude of platelet inhibition across agents. To assess the association between ARS scores and incident bleeding, ARS scores were calculated in patients undergoing cardiac catheterization (N = 1421), of whom 25.4% experienced bleeding events over a median 6.2 years of follow-up. In a Cox model adjusting for demographics and baseline antithrombotic medication use, patients with ARS scores above the median had a higher risk of incident bleeding [hazard ratio 1.26 (95% CI 1.01-1.56), P = 0.038]. CONCLUSIONS The ARS is an Antiplatelet Response Signature that increases in response to greater platelet inhibition due to antiplatelet therapy and may represent a homeostatic mechanism to prevent bleeding. ARS scores could inform future strategies to prevent bleeding while maintaining antiplatelet therapy's benefit of ischaemic cardiovascular event protection.
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Affiliation(s)
- Kevin A Friede
- Center for Applied Genomics & Precision Medicine, Duke University, 101 Science Dr, DUMC 3382, Durham, NC, USA
- Division of Cardiology, Duke University, Durham, NC, USA
| | - Rachel A Myers
- Center for Applied Genomics & Precision Medicine, Duke University, 101 Science Dr, DUMC 3382, Durham, NC, USA
- Division of Cardiology, Duke University, Durham, NC, USA
| | - Jordan Gales
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Ilya Zhbannikov
- Center for Applied Genomics & Precision Medicine, Duke University, 101 Science Dr, DUMC 3382, Durham, NC, USA
- Division of Cardiology, Duke University, Durham, NC, USA
| | - Thomas L Ortel
- Division of Hematology, Duke University, Durham, NC, USA
| | - Svati H Shah
- Division of Cardiology, Duke University, Durham, NC, USA
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - William E Kraus
- Division of Cardiology, Duke University, Durham, NC, USA
- Duke Molecular Physiology Institute, Duke University, Durham, NC, USA
| | - Geoffrey S Ginsburg
- All of Us Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Deepak Voora
- Center for Applied Genomics & Precision Medicine, Duke University, 101 Science Dr, DUMC 3382, Durham, NC, USA
- Division of Cardiology, Duke University, Durham, NC, USA
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Infeld M, Friede KA, San TR, Knickerbocker HJ, Ginsburg GS, Ortel TL, Voora D. Platelet reactivity in response to aspirin and ticagrelor in African-Americans and European-Americans. J Thromb Thrombolysis 2021; 51:249-259. [PMID: 33159252 PMCID: PMC7889728 DOI: 10.1007/s11239-020-02327-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/30/2020] [Indexed: 12/19/2022]
Abstract
Platelet gene polymorphisms are associated with variable on-treatment platelet reactivity and vary by race. Whether differences in platelet reactivity and aspirin or ticagrelor exist between African-American and European-Americans remains poorly understood. Biological samples from three prior prospective antiplatelet challenge studies at the Duke Clinical Research Unit were used to compare platelet reactivity between African-American and European-American subjects. Platelet reactivity at baseline, on-aspirin, on-ticagrelor, and the treatment effect of aspirin or ticagrelor were compared between groups using an adjusted mixed effects model. Compared with European-Americans (n = 282; 50% female; mean ± standard deviation age, 50 ± 16), African-Americans (n = 209; 67% female; age 48 ± 12) had lower baseline platelet reactivity with platelet function analyzer-100 (PFA-100) (p < 0.01) and with light transmission aggregometry (LTA) in response to arachidonic acid (AA), adenosine diphosphate (ADP), and epinephrine agonists (p < 0.05). African-Americans had lower platelet reactivity on aspirin in response to ADP, epinephrine, and collagen (p < 0.05) and on ticagrelor in response to AA, ADP, and collagen (p < 0.05). The treatment effect of aspirin was greater in European-Americans with an AA agonist (p = 0.002). Between-race differences with in vitro aspirin mirrored those seen in vivo. The treatment effect of ticagrelor was greater in European-Americans in response to ADP (p < 0.05) but with collagen, the treatment effect was greater for African-Americans (p < 0.05). Platelet reactivity was overall lower in African-Americans off-treatment, on aspirin, and on ticagrelor. European-Americans experienced greater platelet suppression on aspirin and on ticagrelor. The aspirin response difference in vivo and in vitro suggests a mechanism intrinsic to the platelet. Whether the absolute level of platelet reactivity or the degree of platelet suppression after treatment is more important for clinical outcomes is uncertain.
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Affiliation(s)
- Margaret Infeld
- Division of Cardiology, Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Kevin A Friede
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Tan Ru San
- Department of Cardiology, National Heart Centre, Singapore, Singapore
| | - Holly J Knickerbocker
- Center for Applied Genomics & Precision Medicine, Duke University, 2187 CIEMAS, Campus Box 3382, Durham, NC, 27708, USA
| | - Geoffrey S Ginsburg
- Center for Applied Genomics & Precision Medicine, Duke University, 2187 CIEMAS, Campus Box 3382, Durham, NC, 27708, USA
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Thomas L Ortel
- Division of Hematology, Duke University, Durham, NC, USA
| | - Deepak Voora
- Center for Applied Genomics & Precision Medicine, Duke University, 2187 CIEMAS, Campus Box 3382, Durham, NC, 27708, USA.
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA.
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Friede KA, Infeld MM, Tan RS, Knickerbocker HJ, Myers RA, Dubois LG, Thompson JW, Kaddurah‐Daouk R, Ginsburg GS, Ortel TL, Voora D. Influence of Sex on Platelet Reactivity in Response to Aspirin. J Am Heart Assoc 2020; 9:e014726. [PMID: 32654613 PMCID: PMC7660714 DOI: 10.1161/jaha.119.014726] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 09/23/2019] [Accepted: 05/06/2020] [Indexed: 01/29/2023]
Abstract
Background There are sex differences in the efficacy and safety of aspirin for the prevention of myocardial infarction and stroke. Whether this is explained by underlying differences in platelet reactivity and aspirin response remains poorly understood. Methods and Results Healthy volunteers (n=378 208 women) and patients with coronary artery disease or coronary artery disease risk factors (n=217 112 women) took aspirin for 4 weeks. Light transmittance aggregometry using platelet-rich plasma was used to measure platelet reactivity in response to epinephrine, collagen, and ADP at baseline, 3 hours after the first aspirin dose, and after 4 weeks of daily aspirin therapy. A subset of patients underwent pharmacokinetic and pharmacodynamic assessment with levels of salicylate and cyclooxygenase-1-derived prostaglandin metabolites and light transmittance aggregometry in response to arachidonic acid and after ex vivo exposure to aspirin. At baseline, women had increased platelet aggregation in response to ADP and collagen. Innate platelet response to aspirin, assessed with ex vivo aspirin exposure of baseline platelets, did not differ by sex. Three hours after the first oral aspirin dose, platelet aggregation was inhibited in women to a greater degree in response to epinephrine and to a lesser degree with collagen. After 4 weeks of daily therapy, despite higher salicylate concentrations and greater cyclooxygenase-1 inhibition, women exhibited an attenuation of platelet inhibition in response to epinephrine and ADP. Conclusions We observed agonist-dependent sex differences in platelet responses to aspirin. Despite higher cyclooxygenase-1 inhibition, daily aspirin exposure resulted in a paradoxical attenuation of platelet inhibition in response to epinephrine and ADP over time in women but not in men.
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Affiliation(s)
- Kevin A. Friede
- Division of CardiologyDuke UniversityDurhamNC
- Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNC
| | - Margaret M. Infeld
- Division of CardiologyLarner College of Medicine at the University of VermontBurlingtonVT
| | - Ru San Tan
- Department of CardiologyNational Heart CentreSingapore
| | | | - Rachel A. Myers
- Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNC
| | - Laura G. Dubois
- Center for Genomic and Computational BiologyDuke UniversityDurhamNC
| | - J. Will Thompson
- Center for Genomic and Computational BiologyDuke UniversityDurhamNC
| | | | - Geoffrey S. Ginsburg
- Division of CardiologyDuke UniversityDurhamNC
- Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNC
| | | | - Deepak Voora
- Division of CardiologyDuke UniversityDurhamNC
- Center for Applied Genomics & Precision MedicineDuke UniversityDurhamNC
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Affiliation(s)
- Kevin A Friede
- Division of Cardiology, Duke University, Duke University Medical Center, 2301 Erwin Road, Durham, NC, USA
| | - Deepak Voora
- Division of Cardiology, Duke University, Duke University Medical Center, 2301 Erwin Road, Durham, NC, USA.,Center for Applied Genomics & Precision Medicine, Duke University, 101 Science DriveBox #3382, CIEMAS Building, Duke University Medical Center, Durham, NC, USA
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Friede KA, Voora D. Future directions in pharmacogenomics discovery in cardiovascular disease. Pharmacogenomics 2018; 19:375-377. [PMID: 29569527 DOI: 10.2217/pgs-2018-0002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Kevin A Friede
- Division of Cardiology, Duke University, Durham, NC 27710, USA
| | - Deepak Voora
- Division of Cardiology, Duke University, Durham, NC 27710, USA.,Duke Center for Applied Genomics & Precision Medicine, Duke University, Durham, NC 27708, USA
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Abstract
Over the past 10-15 years, developments in gene expression profiling have opened new arenas for the discovery of important factors in the pathogenesis of numerous disease processes, including coronary artery disease. Messenger RNA and microRNA are differentially expressed in patients with coronary plaques, acute plaque rupture, and response to well-established treatments for acute coronary syndromes. In this review, we will explore recent developments in messenger RNA and microRNA technology at each stage of a patient's progression through the natural history of cardiovascular disease, including evaluation of risk factors, prediction and detection of coronary artery disease and acute coronary syndromes, and finally, response to treatments for coronary artery disease and its sequelae including congestive heart failure.
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Affiliation(s)
- Kevin A Friede
- Department of Medicine, Duke University, Durham, NC, USA
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Friede KA, Osborne MC, Erickson DJ, Roesler JS, Azam A, Croston JK, McGonigal MD, Ney AL. Predicting trauma admissions: the effect of weather, weekday, and other variables. Minn Med 2009; 92:47-49. [PMID: 20069999] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
One of the challenges all hospitals, especially designated trauma centers, face is how to make sure they have adequate staffing on various days of the week and at various times of the year. A number of studies have explored whether factors such as weather, temporal variation, holidays, and events that draw mass gatherings may be useful for predicting patient volume. This article looks at the effects of weather, mass gatherings, and calendar variables on daily trauma admissions at the three Level I trauma hospitals in the Minneapolis-St. Paul metropolitan area. Using ARIMA statistical modeling, we found that weekends, summer, lack of rain, and snowfall were all predictive of daily trauma admissions; holidays and mass gatherings such as sporting events were not. The forecasting model was successful in reflecting the pattern of trauma admissions; however, it's usefulness was limited in that the predicted range of daily trauma admissions was much narrower than the observed number of admissions. Nonetheless, the observed pattern of increased admission in the summer months and year-round on Saturdays should be helpful in resource planning.
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Affiliation(s)
- Kevin A Friede
- Duke University School of Medicine, Durham, North Carolina, USA
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