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Abughofah Y, Anderson WL, Kreutz RP. Renal Dysfunction and Outcomes in Patients With ST-Elevation Myocardial Infarction Treated With Percutaneous Coronary Intervention. Am J Cardiol 2024; 217:35-38. [PMID: 38408591 DOI: 10.1016/j.amjcard.2024.01.039] [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: 10/09/2023] [Revised: 01/13/2024] [Accepted: 01/29/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Yousaf Abughofah
- Indiana University School of Medicine, Division of Cardiovascular Medicine, Indianapolis, Indiana
| | - Wesley L Anderson
- Indiana University School of Medicine, Division of Cardiovascular Medicine, Indianapolis, Indiana
| | - Rolf P Kreutz
- Indiana University School of Medicine, Division of Cardiovascular Medicine, Indianapolis, Indiana.
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Kreutz RP, Leon IG, Bain ER, George B, Phookan S, Prakash A, Sinha AK, Breall JA, Zenisek JR, Frick KA, Jaradat ZA, Abu Romeh IS, O'Leary B, Kalra A, Kumar A, Lee MS, von der Lohe E. Heparin Dosing During Percutaneous Coronary Intervention and Obesity. J Cardiovasc Pharmacol 2024; 83:251-257. [PMID: 38086077 DOI: 10.1097/fjc.0000000000001525] [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: 08/23/2023] [Accepted: 11/16/2023] [Indexed: 03/08/2024]
Abstract
ABSTRACT Unfractionated heparin is the most common anticoagulant used during percutaneous coronary intervention. Practice guidelines recommend an initial weight-based heparin bolus dose between 70 and 100 U/kg to achieve target activated clotting time (ACT) of 250-300 seconds. The impact of severe obesity on weight-based heparin dosing is not well studied. We performed a retrospective analysis of 424 patients undergoing percutaneous coronary intervention who received heparin for anticoagulation. We collected detailed data on cumulative heparin administration and measured ACT values in this cohort. We performed separate analyses to identify clinical predictors that may affect dose-response curves. There was significant variability in dosing with mean dose of 103.9 ± 32-U/kg heparin administered to achieve target ACT ≥ 250 seconds. Women received higher initial heparin doses when adjusted for weight than men (97.6 ± 31 vs. 89 ± 28 U/kg, P = 0.004), and only 49% of patients achieved ACT ≥ 250 s with the initial recommended heparin bolus dose (70-100 U/kg). Lower heparin dose (U/kg) was required in obese patients to achieve target ACT. In multivariate linear regression analysis with ACT as dependent variable, after inclusion of weight-based dosing for heparin, body mass index was the only significant covariate. In conclusion, there is significant variability in the therapeutic effect of heparin, with a lower weight-adjusted heparin dose required in obese patients.
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Affiliation(s)
- Rolf P Kreutz
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Isaac G Leon
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Eric R Bain
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Bistees George
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Sujoy Phookan
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Anjali Prakash
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Anjan K Sinha
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Jeffrey A Breall
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Joseph R Zenisek
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Kyle A Frick
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Ziad A Jaradat
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Ibrahim S Abu Romeh
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Brian O'Leary
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
| | - Ankur Kalra
- Cardiology, Franciscan Health, Lafayette, IN
| | - Ashish Kumar
- Department of Medicine, Cleveland Clinic Akron General, Akron, OH; and
| | - Michael S Lee
- Division of Cardiology, University of California, Los Angeles Medical Center, Los Angeles, CA
| | - Elisabeth von der Lohe
- Division of Cardiovascular Medicine, Indiana University School of Medicine/Indiana University Health Methodist, Indianapolis, IN
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Eadon MT, Rosenman MB, Zhang P, Fulton CR, Callaghan JT, Holmes AM, Levy KD, Gupta SK, Haas DM, Vuppalanchi R, Benson EA, Kreutz RP, Tillman EM, Shugg T, Pierson RC, Gufford BT, Pratt VM, Zang Y, Desta Z, Dexter PR, Skaar TC. The INGENIOUS trial: Impact of pharmacogenetic testing on adverse events in a pragmatic clinical trial. Pharmacogenomics J 2023; 23:169-177. [PMID: 37689822 PMCID: PMC10805517 DOI: 10.1038/s41397-023-00315-w] [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: 03/22/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
Adverse drug events (ADEs) account for a significant mortality, morbidity, and cost burden. Pharmacogenetic testing has the potential to reduce ADEs and inefficacy. The objective of this INGENIOUS trial (NCT02297126) analysis was to determine whether conducting and reporting pharmacogenetic panel testing impacts ADE frequency. The trial was a pragmatic, randomized controlled clinical trial, adapted as a propensity matched analysis in individuals (N = 2612) receiving a new prescription for one or more of 26 pharmacogenetic-actionable drugs across a community safety-net and academic health system. The intervention was a pharmacogenetic testing panel for 26 drugs with dosage and selection recommendations returned to the health record. The primary outcome was occurrence of ADEs within 1 year, according to modified Common Terminology Criteria for Adverse Events (CTCAE). In the propensity-matched analysis, 16.1% of individuals experienced any ADE within 1-year. Serious ADEs (CTCAE level ≥ 3) occurred in 3.2% of individuals. When combining all 26 drugs, no significant difference was observed between the pharmacogenetic testing and control arms for any ADE (Odds ratio 0.96, 95% CI: 0.78-1.18), serious ADEs (OR: 0.91, 95% CI: 0.58-1.40), or mortality (OR: 0.60, 95% CI: 0.28-1.21). However, sub-group analyses revealed a reduction in serious ADEs and death in individuals who underwent pharmacogenotyping for aripiprazole and serotonin or serotonin-norepinephrine reuptake inhibitors (OR 0.34, 95% CI: 0.12-0.85). In conclusion, no change in overall ADEs was observed after pharmacogenetic testing. However, limitations incurred during INGENIOUS likely affected the results. Future studies may consider preemptive, rather than reactive, pharmacogenetic panel testing.
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Affiliation(s)
- Michael T Eadon
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Marc B Rosenman
- Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Pengyue Zhang
- Indiana University School of Medicine, Department of Biostatistics and Heath Data Science, Indianapolis, IN, USA
| | - Cathy R Fulton
- Luddy School of Informatics, Computing, and Engineering, Indianapolis, IN, 46202, USA
| | - John T Callaghan
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Ann M Holmes
- Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN, 46202, USA
| | - Kenneth D Levy
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Samir K Gupta
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - David M Haas
- Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN, USA
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Eric A Benson
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Emma M Tillman
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Tyler Shugg
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Rebecca C Pierson
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
- Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN, USA
- Community Fertility Specialty Care, Indianapolis, IN, USA
| | - Brandon T Gufford
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Victoria M Pratt
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN, USA
| | - Yong Zang
- Indiana University School of Medicine, Department of Biostatistics and Heath Data Science, Indianapolis, IN, USA
| | - Zeruesenay Desta
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Paul R Dexter
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USA.
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis, IN, USA.
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Kreutz RP, Ipe J, Skaar TC. Sex specific differences of factor XI and relationship with other coagulation factors. Thromb Res 2023; 226:156-158. [PMID: 37167906 DOI: 10.1016/j.thromres.2023.04.004] [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] [Received: 01/31/2023] [Revised: 03/20/2023] [Accepted: 04/05/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Rolf P Kreutz
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, USA.
| | - Joseph Ipe
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, USA
| | - Todd C Skaar
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, USA
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Powell NR, Shugg T, Leighty J, Martin M, Kreutz RP, Eadon MT, Lai D, Lu T, Skaar TC. Analysis of the Combined Effect of rs699 and rs5051 on Angiotensinogen Expression and Hypertension. bioRxiv 2023:2023.04.07.536073. [PMID: 37066278 PMCID: PMC10104131 DOI: 10.1101/2023.04.07.536073] [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: 04/18/2023]
Abstract
Hypertension (HTN) involves genetic variability in the renin-angiotensin system and characterizing this variability will help advance precision antihypertensive treatments. We previously reported that angiotensinogen (AGT) mRNA is endogenously bound by mir-122-5p and that rs699 A>G significantly decreases reporter mRNA in the functional mirSNP assay PASSPORT-seq. The AGT promoter variant rs5051 C>T is in linkage disequilibrium (LD) with rs699 A>G and increases AGT transcription. We hypothesized that the increased AGT by rs5051 C>T counterbalances AGT decrease by rs699 A>G, and when these variants occur independently, would translate to HTN-related phenotypes. The independent effect of each of these variants is understudied due to their LD, therefore, we used in silico, in vitro, in vivo, and retrospective clinical and biobank analyses to assess HTN and AGT expression phenotypes where rs699 A>G occurs independently from rs5051 C>T. In silico, rs699 A>G is predicted to increase mir-122-5p binding strength by 3%. Mir-eCLIP assay results show that rs699 is 40-45 nucleotides from the strongest microRNA binding site in the AGT mRNA. Unexpectedly, rs699 A>G increases AGT mRNA in a plasmid cDNA HepG2 expression model. GTEx and UK Biobank analyses demonstrate that liver AGT expression and HTN phenotypes were not different when rs699 A>G occurs independently from rs5051 C>T, allowing us to reject the original hypothesis. However, both GTEx and our in vitro experiments suggest rs699 A>G confers cell-type specific effects on AGT mRNA abundance. We found that rs5051 C>T and rs699 A>G significantly associate with systolic blood pressure in Black participants in the UK Biobank, demonstrating a 4-fold larger effect than in White participants. Further studies are warranted to determine if the altered antihypertensive response in Black individuals might be due to rs5051 C>T or rs699 A>G. Studies like this will help clinicians move beyond the use of race as a surrogate for genotype.
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Affiliation(s)
- Nicholas R. Powell
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis IN
| | - Tyler Shugg
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis IN
| | - Jacob Leighty
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis IN
| | - Matthew Martin
- Indiana University School of Medicine, Department of Pharmacology and Toxicology, Indianapolis IN
| | - Rolf P. Kreutz
- Indiana University School of Medicine, Department of Cardiology, Krannert Institute of Cardiology, Indianapolis IN
| | - Michael T. Eadon
- Indiana University School of Medicine, Department of Medicine, Division of Nephrology, Indianapolis IN
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis IN
| | - Dongbing Lai
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis IN
| | - Tao Lu
- Indiana University School of Medicine, Department of Pharmacology and Toxicology, Indianapolis IN
| | - Todd C. Skaar
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis IN
- Indiana University School of Medicine, Department of Medical and Molecular Genetics, Indianapolis IN
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Torabi AJ, Von der Lohe E, Kovacs RJ, Frick KA, Kreutz RP. Measures of social deprivation and outcomes after percutaneous coronary intervention. Catheter Cardiovasc Interv 2023; 101:995-1000. [PMID: 36994863 DOI: 10.1002/ccd.30642] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/08/2023] [Accepted: 03/08/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Disparities in socioeconomic status are a frequently cited factor associated with worse cardiovascular outcomes. The social deprivation index (SDI) can be used to quantify socioeconomic resources at the population level. OBJECTIVES The aim of this study was to assess the association of SDI with clinical outcomes following percutaneous coronary interventions (PCI). METHODS This was a retrospective observational analysis of patients who underwent PCI and were included in a multicenter cardiac catheterization registry study. Baseline characteristics, congestive heart failure (CHF) readmission rates and survival were compared between patients with the highest and lower SDI. SDI was calculated based on the US community survey census tract-level data. RESULTS Patients within the highest SDI quintile (n = 1843) had more comorbidities and a higher risk of death [hazard ratio (HR): 1.22 (95% confidence interval, CI: 1.1-1.39, p = 0.004); log rank: p = 0.009] and CHF readmission [HR: 1.56 (1.39-1.75, p < 0.001); log rank: p < 0.001) as compared with those in the lower quintiles (n = 10,201) during mean follow-up of 3 years. Increased risk of highest SDI for all-cause mortality and CHF remained significant after adjustment in multivariable analysis for factors associated with highest SDI. CONCLUSIONS Patients within the highest SDI quintile had a greater proportion of comorbidities as well as higher risk for adverse outcomes as compared with patients with a lower SDI following PCI.
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Affiliation(s)
- Asad J Torabi
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elisabeth Von der Lohe
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard J Kovacs
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kyle A Frick
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rolf P Kreutz
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Cavallari LH, Limdi NA, Beitelshees AL, Lee JC, Duarte JD, Franchi F, Tuteja S, Giri J, Empey PE, Kreutz RP, Skaar TC, Allen JM, Coons JC, Gong Y, McDonough CW, Stevenson JM, Thomas CD, Johnson JA, Stouffer GA, Angiolillo DJ, Lee CR. Evaluation of Potential Racial Disparities in CYP2C19-Guided P2Y 12 Inhibitor Prescribing After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2023; 113:615-623. [PMID: 36306392 PMCID: PMC9957848 DOI: 10.1002/cpt.2776] [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: 07/08/2022] [Accepted: 10/21/2022] [Indexed: 01/16/2023]
Abstract
Black patients suffer worse outcomes after percutaneous coronary intervention (PCI) than White patients. Inequities in antiplatelet prescribing may contribute to this health disparity. We compared P2Y12 inhibitor prescribing by race following CYP2C19 genotyping to guide antiplatelet therapy selection after PCI. Patients from 9 sites that performed clinical CYP2C19 genotyping after PCI were included. Alternative therapy (e.g., prasugrel or ticagrelor) was recommended for CYP2C19 no-function allele carriers, in whom clopidogrel is predicted to be less effective. The primary outcome was choice of P2Y12 inhibitor (clopidogrel vs. alternative therapy) based on genotype. Of 3,342 patients included, 2,448 (73%) were White, and 659 (20%) were Black. More Black than White patients had a no-function allele (34.3% vs. 29.7%, P = 0.024). At hospital discharge following PCI, 44.2% of Black and 44.0% of White no-function allele carriers were prescribed alternative therapy. At the time of the last follow-up within 12 months, numerically fewer Black (51.8%) than White (56.7%) no-function allele carriers were prescribed alternative therapy (P = 0.190). However, the difference was not significant after accounting for other factors associated with P2Y12 inhibitor selection (odds ratio 0.79, 95% confidence interval 0.58-1.08). Alternative therapy use did not differ between Black (14.3%) and White (16.7%) patients without a no-function allele (P = 0.232). Among real-world patients who received CYP2C19 testing after PCI, P2Y12 inhibitor prescribing rates did not differ between Black and White patients. Our data suggest an absence of racial disparity in genotype-guided antiplatelet prescribing among patients receiving CYP2C19 testing.
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Affiliation(s)
- Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Nita A. Limdi
- Department of Neurology, Program for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, AL
| | - Amber L. Beitelshees
- University of Maryland School of Medicine, Department of Medicine and Program for Personalized and Genomic Medicine, Baltimore, MD
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Philip E. Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | | | - Todd C. Skaar
- Indiana University School of Medicine, Indianapolis, IN
| | - John M. Allen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Orlando, FL
| | - James C. Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida College of Pharmacy, Gainesville, FL
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
| | | | - Craig R. Lee
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Mahalwar G, Kumar A, Majmundar M, Adebolu O, Yendamuri R, Lao N, Barve N, Kreutz RP, Reed GW, Puri R, Dani SS, Kalra A. Antithrombotic Strategy After Transcatheter Aortic Valve Replacement: A Network Meta-Analysis. Curr Probl Cardiol 2022; 47:101348. [DOI: 10.1016/j.cpcardiol.2022.101348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022]
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Onuoha CP, Ipe J, Simpson E, Liu Y, Skaar T, Kreutz RP. MicroRNA
sequencing in patients with coronary artery disease – considerations for use as biomarker for thrombotic risk. Clin Transl Sci 2022; 15:1946-1958. [PMID: 35643946 PMCID: PMC9372418 DOI: 10.1111/cts.13307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/24/2022] [Accepted: 04/30/2022] [Indexed: 12/05/2022] Open
Abstract
MicroRNAs (miRNAs) are small RNAs integral in the regulation of gene expression. Analysis of circulating miRNA levels may identify patients with coronary artery disease (CAD) at risk for recurrent myocardial infarction (MI) after percutaneous coronary interventions (PCIs). Subjects with CAD were selected from the GENCATH cardiac catheterization biobank. Subjects with recurrent MI after PCI were compared with those without recurrent MI during follow‐up in the initial (n = 48) and replication cohort (n = 67). Next generation MiRNA sequencing was performed on plasma samples and whole blood samples fixed with PAXGENE tubes upon collection. Overall, 164 miRNAs derived from whole blood were differentially expressed in the replication cohort between subjects with and without recurrent MI events (p < 0.05), with 69 remaining significant after false‐discovery rate (FDR) correction. None of the miRNAs in plasma was significantly different by FDR among subjects with and without MI. Overall, correlation between direction of effects between plasma and whole blood assays was variable, and only two miRNAs were concordant and significant in both. Associations of miRNA with vascular disease, MI, and thrombosis were further explored. MiRNA profiling has potential as the future biomarker for disease prognosis and treatment response marker in secondary treatment of patients with CAD after PCI. Whole blood may be the preferred sample source as compared to plasma.
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Affiliation(s)
- Chimnonso P. Onuoha
- Department of Medicine/Clinical Pharmacology Indiana University School of Medicine Indianapolis Indiana USA
| | - Joseph Ipe
- Department of Medicine/Clinical Pharmacology Indiana University School of Medicine Indianapolis Indiana USA
| | - Edward Simpson
- Center for Medical Genomics Indiana University School of Medicine Indianapolis Indiana USA
| | - Yunlong Liu
- Center for Medical Genomics Indiana University School of Medicine Indianapolis Indiana USA
| | - Todd C. Skaar
- Department of Medicine/Clinical Pharmacology Indiana University School of Medicine Indianapolis Indiana USA
| | - Rolf P. Kreutz
- Department of Medicine/Cardiology Indiana University School of Medicine Indianapolis Indiana USA
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Beitelshees AL, Thomas CD, Empey PE, Stouffer GA, Angiolillo DJ, Franchi F, Tuteja S, Limdi NA, Lee JC, Duarte JD, Kreutz RP, Skaar TC, Coons JC, Giri J, McDonough CW, Rowland R, Stevenson JM, Thai T, Vesely MR, Wellen JT, Johnson JA, Winterstein AG, Cavallari LH, Lee CR. CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention in Diverse Clinical Settings. J Am Heart Assoc 2022; 11:e024159. [PMID: 35156424 PMCID: PMC9245803 DOI: 10.1161/jaha.121.024159] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Studies have demonstrated increased risk of major atherothrombotic events in CYP2C19 loss-of-function (LOF) variant carriers versus non-carriers treated with clopidogrel after percutaneous coronary intervention (PCI). We sought to evaluate real-world outcomes with the clinical implementation of CYP2C19-guided antiplatelet therapy after PCI. Methods and Results Data from 9 medical centers where genotyping was performed in the setting of PCI were included. Alternative therapy with prasugrel or ticagrelor was recommended for patients with a CYP2C19 LOF variant. The primary outcome was the composite of major atherothrombotic events (all-cause death, myocardial infarction, ischemic stroke, stent thrombosis, or hospitalization for unstable angina) within 12 months following PCI. Moderate or severe/life-threatening bleeding within 12 months was a secondary outcome. Among 3342 patients, 1032 (31%) were LOF carriers, of whom 571/1032 (55%) were treated with alternative therapy. In LOF carriers, the rate of major atherothrombotic events was lower in patients treated with alternative therapy versus clopidogrel (adjusted HR, 0.56; 95% CI 0.39-0.82). In those without a LOF allele, no difference was observed (adjusted HR, 1.07; 95% CI 0.71-1.60). There was no difference in bleeding with alternative therapy versus clopidogrel in either LOF carriers or those without a LOF allele. Conclusions Real-world data demonstrate lower atherothrombotic risk in CYP2C19 LOF carriers treated with alternative therapy versus clopidogrel and similar risk in those without a LOF allele treated with clopidogrel or alternative therapy. These data suggest that PCI patients treated with clopidogrel should undergo genotyping so that CYP2C19 LOF carriers can be identified and treated with alternative therapy.
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Affiliation(s)
- Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Cameron D. Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Philip E. Empey
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - George A. Stouffer
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC
| | | | - Francesco Franchi
- University of Florida College of Medicine‐JacksonvilleJacksonvilleFL
| | - Sony Tuteja
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Nita A. Limdi
- Department of NeurologyProgram for Translational Pharmacogenomics and Hugh Kaul Personalized Medicine InstituteSchool of MedicineUniversity of Alabama at BirminghamAL
| | - James C. Lee
- Department of Pharmacy PracticeUniversity of Illinois at ChicagoIL
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | | | | | - James C. Coons
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA
| | - Jay Giri
- Cardiovascular Medicine DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Caitrin W. McDonough
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Rachel Rowland
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - James M. Stevenson
- Department of Pharmacy and TherapeuticsUniversity of Pittsburgh School of PharmacyPittsburghPA,Division of Clinical PharmacologyJohns Hopkins University School of MedicineBaltimoreMD
| | - Thuy Thai
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Jacob T. Wellen
- Department of Medicine and Program for Personalized and Genomic MedicineUniversity of Maryland School of MedicineBaltimoreMD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Almut G. Winterstein
- Department of Pharmaceutical Outcomes & Policy and Center for Drug Evaluation and SafetyUniversity of FloridaGainesvilleFL
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision MedicineUniversity of Florida College of PharmacyGainesvilleFL
| | - Craig R. Lee
- Division of Cardiology and McAllister Heart InstituteUniversity of North Carolina, Chapel HillNC,Division of Pharmacotherapy and Experimental TherapeuticsUNC Eshelman School of PharmacyUniversity of North Carolina at Chapel HillNC
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11
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Torabi AJ, Mshelbwala FS, Hugenberg D, Kovacs RJ, Kreutz RP. Social deprivation index and ischemic events after percutaneous coronary intervention in patients with diabetes mellitus. Catheter Cardiovasc Interv 2022; 99:1015-1021. [DOI: 10.1002/ccd.30108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/17/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Asad J. Torabi
- Division of Cardiology, Krannert Institute of Cardiology Indiana University School of Medicine Indianapolis Indiana USA
| | | | - Daniel Hugenberg
- Division of Cardiology Parkview Physicians Group Fort Wayne Indiana USA
| | - Richard J. Kovacs
- Division of Cardiology, Krannert Institute of Cardiology Indiana University School of Medicine Indianapolis Indiana USA
| | - Rolf P. Kreutz
- Division of Cardiology, Krannert Institute of Cardiology Indiana University School of Medicine Indianapolis Indiana USA
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12
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Abstract
High on treatment platelet reactivity (HPR) during treatment with clopidogrel has been consistently found to be strong risk factor for recurrent ischemic events after percutaneous coronary intervention (PCI). Insufficient P2Y12 receptor inhibition contributes to HPR measured by the VerifyNow (VN) assay. Prasugrel and ticagrelor are more potent P2Y12 inhibitors than clopidogrel and commonly substituted for clopidogrel when HPR is documented, however benefit of VN guided intensified antiplatelet therapy is uncertain. We identified patients who had undergone platelet reactivity testing after PCI with VN after pretreatment with clopidogrel (n = 252) in a single center observational analysis. Patients who had HPR defined as PRU > 208 were switched to alternate P2Y12 inhibitors. Primary clinical endpoint was 1-year post PCI combined cardiovascular death, myocardial infarction (MI), and stent thrombosis. One hundred and eight (43%) subjects had HPR and were switched to prasugrel (n = 60) and ticagrelor (n = 48). Risk of recurrent 1-year primary endpoint remained higher for HPR patients switched to either ticagrelor or prasugrel as compared to subjects who had low on treatment platelet reactivity (n = 144) (LPR) on clopidogrel [Hazard Ratio: 3.5 (95% CI 1.1-11.1); p = 0.036)]. Propensity score matched analysis demonstrated higher event rates in patients with HPR on alternate P2Y12 inhibitor as compared to patients with LPR (log-rank: p = 0.044). The increased risk of recurrent events associated with HPR measured by VN is not completely attenuated by switching to more potent P2Y12 inhibitors. Non-P2Y12 mediated pathways likely contribute to increased incidence of thrombotic events after PCI in subjects with HPR.
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Affiliation(s)
- Fakilahyel S Mshelbwala
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Daniel W Hugenberg
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
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13
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Chaudhary R, Bliden KP, Kreutz RP, Jeong YH, Tantry US, Levy JH, Gurbel PA. Race-Related disparities in COVID-19 thrombotic outcomes: Beyond social and economic explanations. EClinicalMedicine 2020; 29:100647. [PMID: 33251501 PMCID: PMC7678450 DOI: 10.1016/j.eclinm.2020.100647] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
- Rahul Chaudhary
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, United States
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kevin P. Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, United States
| | - Rolf P. Kreutz
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
- Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea Institute of the Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, United States
| | - Jerrold H. Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Paul A. Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, United States
- Corresponding author.
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14
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Lee CR, Thomas CD, Beitelshees AL, Tuteja S, Empey PE, Lee JC, Limdi NA, Duarte JD, Skaar TC, Chen Y, Cook KJ, Coons JC, Dillon C, Franchi F, Giri J, Gong Y, Kreutz RP, McDonough CW, Stevenson JM, Weck KE, Angiolillo DJ, Johnson JA, Stouffer GA, Cavallari LH. Impact of the CYP2C19*17 Allele on Outcomes in Patients Receiving Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Clin Pharmacol Ther 2020; 109:705-715. [PMID: 32897581 DOI: 10.1002/cpt.2039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/18/2020] [Indexed: 01/03/2023]
Abstract
Genotyping for CYP2C19 no function alleles to guide antiplatelet therapy after percutaneous coronary intervention (PCI) improves clinical outcomes. Although results for the increased function CYP2C19*17 allele are also reported, its clinical relevance in this setting remains unclear. A collaboration across nine sites examined antiplatelet therapy prescribing and clinical outcomes in 3,342 patients after implementation of CYP2C19-guided antiplatelet therapy. Risk of major atherothrombotic and bleeding events over 12 months after PCI were compared across cytochrome P450 2C19 isozyme (CYP2C19) metabolizer phenotype and antiplatelet therapy groups by proportional hazards regression. Clopidogrel was prescribed to a similar proportion of CYP2C19 normal (84.5%), rapid (82.9%), and ultrarapid metabolizers (80.6%) (P = 0.360). Clopidogrel-treated normal metabolizers (20.4 events/100 patient-years; adjusted hazard ratio (HR) 1.00, 95% confidence interval (CI), 0.75-1.33, P = 0.993) and clopidogrel-treated rapid or ultrarapid metabolizers (19.1 events/100 patient-years; adjusted HR 0.95, 95% CI, 0.69-1.30, P = 0.734) exhibited no difference in major atherothrombotic events compared with patients treated with prasugrel or ticagrelor (17.6 events/100 patient-years). In contrast, clopidogrel-treated intermediate and poor metabolizers exhibited significantly higher atherothrombotic event risk compared with prasugrel/ticagrelor-treated patients (adjusted HR 1.56, 95% CI, 1.12-2.16, P = 0.008). When comparing clopidogrel-treated rapid or ultrarapid metabolizers to normal metabolizers, no difference in atherothrombotic (adjusted HR 0.97, 95% CI, 0.73-1.29, P = 0.808) or bleeding events (adjusted HR 1.34, 95% CI, 0.83-2.17, P = 0.224) were observed. In a real-world setting of genotype-guided antiplatelet therapy, the CYP2C19*17 allele did not significantly impact post-PCI prescribing decisions or clinical outcomes. These results suggest the CYP2C19 *1/*17 and *17/*17 genotypes have limited clinical utility to guide antiplatelet therapy after PCI.
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Affiliation(s)
- Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cameron D Thomas
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Sony Tuteja
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Philip E Empey
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nita A Limdi
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julio D Duarte
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yiqing Chen
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Kelsey J Cook
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James C Coons
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chrisly Dillon
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Jay Giri
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - Rolf P Kreutz
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - James M Stevenson
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Karen E Weck
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, Florida, USA
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15
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Maatman TK, Jalali F, Feizpour C, Douglas A, McGuire SP, Kinnaman G, Hartwell JL, Maatman BT, Kreutz RP, Kapoor R, Rahman O, Zyromski NJ, Meagher AD. Routine Venous Thromboembolism Prophylaxis May Be Inadequate in the Hypercoagulable State of Severe Coronavirus Disease 2019. Crit Care Med 2020; 48:e783-e790. [PMID: 32459672 PMCID: PMC7302085 DOI: 10.1097/ccm.0000000000004466] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [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] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this study was to determine the frequency of venous thromboembolism in critically ill coronavirus disease 2019 patients and associate a degree of inflammatory marker elevation to venous thromboembolism development. DESIGN An observational study that identified patients with severe coronavirus disease 2019 between March 12, 2020, and March 31, 2020. Data reported are those available through May 6, 2020. SETTING A multicenter study including three Indianapolis area academic hospitals. PATIENTS Two-hundred forty consecutive patients with confirmed severe acute respiratory syndrome coronavirus 2 infection were admitted to one of three hospitals. One-hundred nine critically ill coronavirus disease 2019 patients admitted to the ICU were included in the analysis. INTERVENTIONS All patients received routine subcutaneous chemical venous thromboembolism prophylaxis. MEASUREMENTS AND MAIN RESULTS The primary outcome of this study was to determine the frequency of venous thromboembolism and the degree of inflammatory and coagulation marker elevation associated with venous thromboembolism development. Descriptive statistics outlined the frequency of venous thromboembolism at any time during severe coronavirus disease 2019. Clinical course and laboratory metrics were compared between patients that developed venous thromboembolism and patients that did not develop venous thromboembolism. Hypercoagulable thromboelastography was defined as two or more hypercoagulable parameters. MAIN RESULTS One-hundred nine patients developed severe coronavirus disease 2019 requiring ICU care. The mean (± SD) age was 61 ± 16 years and 57% were male. Seventy-five patients (69%) were discharged home, 7 patients (6%) remain in the hospital, and 27 patients (25%) died. Venous thromboembolism was diagnosed in 31 patients (28%) 8 ± 7 days after hospital admission, including two patients diagnosed with venous thromboembolism at presentation to the hospital. Elevated admission D-dimer and peak D-dimer were associated with venous thromboembolism development (p < 0.05). D-dimer greater than 2,600 ng/mL predicted venous thromboembolism with an area under the receiver operating characteristic curve of 0.760 (95% CI, 0.661-0.858; p < 0.0001), sensitivity of 89.7%, and specificity of 59.5%. Twelve patients (11%) had thromboelastography performed and 58% of these patients had a hypercoagulable study. The calculated coagulation index was hypercoagulable in 50% of patients with thromboelastography. CONCLUSIONS These data show that coronavirus disease 2019 results in a hypercoagulable state. Routine chemical venous thromboembolism prophylaxis may be inadequate in preventing venous thromboembolism in severe coronavirus disease 2019.
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Affiliation(s)
- Thomas K Maatman
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Farid Jalali
- Department of Gastroenterology, Saddleback Medical Group, Laguna Hills, CA
| | - Cyrus Feizpour
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | - Sean P McGuire
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | - Jennifer L Hartwell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin T Maatman
- Krannert Institute of Cardiology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Rolf P Kreutz
- Krannert Institute of Cardiology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Rajat Kapoor
- Department of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Omar Rahman
- Department of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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16
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Chaudhary R, Kreutz RP, Bliden KP, Tantry US, Gurbel PA. Personalizing Antithrombotic Therapy in COVID-19: Role of Thromboelastography and Thromboelastometry. Thromb Haemost 2020; 120:1594-1596. [PMID: 32679595 DOI: 10.1055/s-0040-1714217] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Rahul Chaudhary
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States.,Sinai Center of Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Rolf P Kreutz
- Department of Internal Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Kevin P Bliden
- Sinai Center of Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Udaya S Tantry
- Sinai Center of Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Paul A Gurbel
- Sinai Center of Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
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17
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Kreutz RP. IL-1R (Interleukin-1 Receptor) Signaling and Attenuated Hepatic CYP (Cytochrome P450) 2C Expression: Explanation for Higher Rate of Clopidogrel Resistance in Patients With Diabetes Mellitus? Arterioscler Thromb Vasc Biol 2020; 40:1429-1431. [PMID: 32459538 DOI: 10.1161/atvbaha.120.314446] [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: 11/16/2022]
Affiliation(s)
- Rolf P Kreutz
- From the Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis
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18
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Mshelbwala FS, Hugenberg DW, Kreutz RP. Impact of Routine Platelet Reactivity Testing with VerifyNow Assay on Antiplatelet Choice After Percutaneous Coronary Intervention. Clin Pharmacol 2020; 12:35-41. [PMID: 32368161 PMCID: PMC7170549 DOI: 10.2147/cpaa.s242675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background High on-treatment ADP platelet reactivity (HPR) measured by VerifyNow P2Y12 assay (VN) is an established risk factor for ischemic events after percutaneous coronary intervention (PCI). We hypothesized that routine use of VN at time of PCI in clinical practice may affect choice of P2Y12 antiplatelet therapy at discharge. Methods In a single center retrospective analysis, we examined the influence of VN testing on choice of P2Y12 inhibitor post PCI in routine clinical practice. Assessment of HPR was used routinely in clinical care during the time period of analysis at discretion of clinical providers. Subjects with PRU>208 after the loading dose of clopidogrel or during clopidogrel steady state were switched to alternate P2Y12 inhibitors. Results We identified 1001 patients with PCI during the time period specified. A total of 252 subjects underwent VN testing. Among those, 43% were found to have HPR on clopidogrel and were switched to alternate therapies (prasugrel [n=60], ticagrelor [n=48]). Patients who had VN platelet function testing were more likely to be discharged on clopidogrel as compared to those who did not have VN assay done (57% vs. 50%, p=0.039). There was no significant difference in 1-year net-MACE (CVD, MI, stent thrombosis, BARC 2 or higher bleeding) using tailored antiplatelet therapy (VN testing) as compared to standard of care group (adjusted HR:0.92, 95% CI: 0.54-1.5, p=0.74). Conclusion Routine use of VN assay in personalized antiplatelet treatment decision-making after PCI is associated with lower likelihood of using novel P2Y12 inhibitors.
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Affiliation(s)
- Fakilahyel S Mshelbwala
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel W Hugenberg
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
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19
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Kanuri SH, Kreutz RP. Pharmacogenomics of Novel Direct Oral Anticoagulants: Newly Identified Genes and Genetic Variants. J Pers Med 2019; 9:jpm9010007. [PMID: 30658513 PMCID: PMC6463033 DOI: 10.3390/jpm9010007] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 01/01/2023] Open
Abstract
Direct oral anticoagulants (DOAC) have shown an upward prescribing trend in recent years due to favorable pharmacokinetics and pharmacodynamics without requirement for routine coagulation monitoring. However, recent studies have documented inter-individual variability in plasma drug levels of DOACs. Pharmacogenomics of DOACs is a relatively new area of research. There is a need to understand the role of pharmacogenomics in the interpatient variability of the four most commonly prescribed DOACs, namely dabigatran, rivaroxaban, apixaban, and edoxaban. We performed an extensive search of recently published research articles including clinical trials and in-vitro studies in PubMed, particularly those focusing on genetic loci, single nucleotide polymorphisms (SNPs), and DNA polymorphisms, and their effect on inter-individual variation of DOACs. Additionally, we also focused on commonly associated drug-drug interactions of DOACs. CES1 and ABCB1 SNPs are the most common documented genetic variants that contribute to alteration in peak and trough levels of dabigatran with demonstrated clinical impact. ABCB1 SNPs are implicated in alteration of plasma drug levels of rivaroxaban and apixaban. Studies conducted with factor Xa, ABCB1, SLCOB1, CYP2C9, and VKORC1 genetic variants did not reveal any significant association with plasma drug levels of edoxaban. Pharmacokinetic drug-drug interactions of dabigatran are mainly mediated by p-glycoprotein. Strong inhibitors and inducers of CYP3A4 and p-glycoprotein should be avoided in patients treated with rivaroxaban, apixaban, and edoxaban. We conclude that some of the inter-individual variability of DOACs can be attributed to alteration of genetic variants of gene loci and drug-drug interactions. Future research should be focused on exploring new genetic variants, their effect, and molecular mechanisms that contribute to alteration of plasma levels of DOACs.
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Affiliation(s)
- Sri H Kanuri
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Rolf P Kreutz
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA.
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20
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Empey PE, Stevenson JM, Tuteja S, Weitzel KW, Angiolillo DJ, Beitelshees AL, Coons JC, Duarte JD, Franchi F, Jeng LJ, Johnson JA, Kreutz RP, Limdi NA, Maloney KA, Obeng AO, Peterson JF, Petry N, Pratt VM, Rollini F, Scott SA, Skaar TC, Vesely MR, Stouffer GA, Wilke RA, Cavallari LH, Lee CR. Multisite Investigation of Strategies for the Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy. Clin Pharmacol Ther 2018; 104:664-674. [PMID: 29280137 PMCID: PMC6019555 DOI: 10.1002/cpt.1006] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [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: 09/18/2017] [Revised: 11/27/2017] [Accepted: 12/20/2017] [Indexed: 01/05/2023]
Abstract
CYP2C19 genotype-guided antiplatelet therapy following percutaneous coronary intervention is increasingly implemented in clinical practice. However, challenges such as selecting a testing platform, communicating test results, building clinical decision support processes, providing patient and provider education, and integrating methods to support the translation of emerging evidence to clinical practice are barriers to broad adoption. In this report, we compare and contrast implementation strategies of 12 early adopters, describing solutions to common problems and initial performance metrics for each program. Key differences between programs included the test result turnaround time and timing of therapy changes, which are both related to the CYP2C19 testing model and platform used. Sites reported the need for new informatics infrastructure, expert clinicians such as pharmacists to interpret results, physician champions, and ongoing education. Consensus lessons learned are presented to provide a path forward for those seeking to implement similar clinical pharmacogenomics programs within their institutions.
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Affiliation(s)
- Philip E. Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - James M. Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Sony Tuteja
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kristin W. Weitzel
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Dominick J. Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Amber L. Beitelshees
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - James C. Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Julio D. Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
| | - Francesco Franchi
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Linda J.B. Jeng
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham AL
| | - Kristin A. Maloney
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - Aniwaa Owusu Obeng
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai; and Pharmacy Department, The Mount Sinai Hospital, New York, NY
| | - Josh F. Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha Petry
- Department of Pharmacy Practice, North Dakota State University, Fargo, ND
| | - Victoria M. Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Fabiana Rollini
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Stuart A. Scott
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY and Sema4, a Mount Sinai venture, Stamford, CT
| | - Todd C. Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN
| | - Mark R. Vesely
- Department of Medicine and Program for Personalized and Genomic Medicine, University of Maryland, Baltimore, MD
| | - George A. Stouffer
- Division of Cardiology, School of Medicine and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Russell A. Wilke
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, Gainesville, FL
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC
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21
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Nguyen KA, Li L, Lu D, Yazdanparast A, Wang L, Kreutz RP, Whipple EC, Schleyer TK. A comprehensive review and meta-analysis of risk factors for statin-induced myopathy. Eur J Clin Pharmacol 2018; 74:1099-1109. [PMID: 29785580 DOI: 10.1007/s00228-018-2482-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/10/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE To aid prescribers in assessing a patient's risk for statin-induced myopathy (SIM), we performed a comprehensive review of currently known risk factors and calculated aggregated odds ratios for each risk factor through a meta-analysis. METHODS This meta-analysis was done through four phases: (1) Identification of the relevant primary literature; (2) abstract screening using inclusion and exclusion criteria; (3) detailed review and data extraction; and (4) synthesis and statistical analysis. RESULTS Out of 44 papers analyzed from 836 papers searched from MEDLINE, 18 different potential risk factors were collected, divided into three categories: three demographics (11 papers), ten clinical factors (31 papers), and five pharmacogenetics/biomarkers (12 papers). Risk factors significant for myopathy and/or rhabdomyolysis included age, gender, diabetes, renal impairment, cardiovascular disease, certain interacting drugs, and mutations of the SLCO1B1 gene, which encodes a transporter protein in the liver. Several factors, such as gender, race, cardiovascular disease, and the GATM gene, which encodes a protein for creatine synthesis, appeared to be protective in terms of the outcomes of interest. CONCLUSIONS This comprehensive assessment of risk factors can help support clinicians in reducing the incidence of SIM in their patient population on statins.
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Affiliation(s)
- Khoa A Nguyen
- Center for Health Information and Communication, Department of Veterans Affairs (VA), Veterans Health Administration, Health Service Research and Development Service (CIN 13-416), Richard L. Roudebush VA Medical Center, D6004-02, 1481 West 10th Street, Indianapolis, IN, 46202, USA. .,Department of Pharmacy Practice, College of Pharmacy, Purdue University, Indianapolis, IN, USA.
| | - Lang Li
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Deshun Lu
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Aida Yazdanparast
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lei Wang
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth C Whipple
- Research and Translational Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Titus K Schleyer
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN, USA
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22
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Kreutz RP, Schmeisser G, Schaffter A, Kanuri S, Owens J, Maatman B, Sinha A, von der Lohe E, Breall JA. Prediction of Ischemic Events after Percutaneous Coronary Intervention: Thrombelastography Profiles and Factor XIIIa Activity. TH Open 2018; 2:e173-e181. [PMID: 30882064 PMCID: PMC6419750 DOI: 10.1055/s-0038-1645876] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background
High plasma fibrin clot strength (MA) measured by thrombelastography (TEG) is associated with increased risk of cardiac events after percutaneous coronary interventions (PCIs). Factor XIIIa (FXIIIa) cross-links soluble fibrin, shortens clot formation time (TEG-K), and increases final clot strength (MA).
Methods
We analyzed platelet-poor plasma from patients with previous PCI. Kaolin-activated TEG (R, K, MA) in citrate platelet-poor plasma and FXIIIa were measured (
n
= 257). Combined primary endpoint was defined as recurrent myocardial infarction (MI) or cardiovascular death (CVD). Relationship of FXIIIa and TEG measurements on cardiac risk was explored.
Results
FXIIIa correlated with TEG-MA (
p
= 0.002) and inversely with TEG-K (
p
< 0.001). High MA (≥35.35 mm;
p
= 0.001), low K (<1.15 min;
p
= 0.038), and elevated FXIIIa (≥83.51%;
p
= 0.011) were associated with increased risk of CVD or MI. Inclusion of FXIIIa activity and low TEG-K in risk scores did not improve risk prediction as compared with high TEG-MA alone.
Conclusion
FXIIIa is associated with higher plasma TEG-MA and low TEG-K. High FXIIIa activity is associated with a modest increase in cardiovascular risk after PCI, but is less sensitive and specific than TEG-MA. Addition of FXIIIa does not provide additional risk stratification beyond risk associated with high fibrin clot strength phenotype measured by TEG.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States.,Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Glen Schmeisser
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Andrea Schaffter
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Sri Kanuri
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Janelle Owens
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States.,Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Benjamin Maatman
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Anjan Sinha
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Elisabeth von der Lohe
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Jeffrey A Breall
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, United States
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23
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Maatman BT, Schmeisser G, Kreutz RP. Fibrin Clot Strength in Patients with Diabetes Mellitus Measured by Thrombelastography. J Diabetes Res 2018; 2018:4543065. [PMID: 29507861 PMCID: PMC5817329 DOI: 10.1155/2018/4543065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/30/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with diabetes mellitus (DM) exhibit increased risk of recurrent myocardial infarction. Maximal clot strength measured by thrombelastography (TEG) is a risk factor for recurrent ischemic events. We hypothesized that diabetic subjects exhibit increased fibrin clot strength in platelet-poor plasma and that glycemic control correlates with maximal fibrin clot strength. METHODS We collected plasma samples from subjects with known or suspected coronary artery disease undergoing cardiac catheterization (n = 354). We measured kaolin-activated TEG in platelet-poor citrate plasma. Time to fibrin formation (R), clot formation time (K), and maximal fibrin clot strength (MA) were recorded. RESULTS Plasma fibrin MA was increased among subjects with DM (n = 152) as compared to non-DM (n = 202) (37.0 ± 8 versus 34.1 ± 8 mm; p < 0.001). Hemoglobin A1c (HbA1c) (ρ = 0.22; p = 0.001) and fibrinogen (ρ = 0.29; p < 0.001) correlated with fibrin MA. In multivariable regression analysis, DM remained significantly associated with plasma MA after adjustment for fibrinogen level (p = 0.003). CONCLUSIONS Subjects with diabetes mellitus exhibit increased maximal fibrin clot strength measured by TEG in platelet-poor plasma.
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Affiliation(s)
- Benjamin T. Maatman
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen Schmeisser
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rolf P. Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
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24
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Cavallari LH, Lee CR, Beitelshees AL, Cooper-DeHoff RM, Duarte JD, Voora D, Kimmel SE, McDonough CW, Gong Y, Dave CV, Pratt VM, Alestock TD, Anderson RD, Alsip J, Ardati AK, Brott BC, Brown L, Chumnumwat S, Clare-Salzler MJ, Coons JC, Denny JC, Dillon C, Elsey AR, Hamadeh IS, Harada S, Hillegass WB, Hines L, Horenstein RB, Howell LA, Jeng LJB, Kelemen MD, Lee YM, Magvanjav O, Montasser M, Nelson DR, Nutescu EA, Nwaba DC, Pakyz RE, Palmer K, Peterson JF, Pollin TI, Quinn AH, Robinson SW, Schub J, Skaar TC, Smith DM, Sriramoju VB, Starostik P, Stys TP, Stevenson JM, Varunok N, Vesely MR, Wake DT, Weck KE, Weitzel KW, Wilke RA, Willig J, Zhao RY, Kreutz RP, Stouffer GA, Empey PE, Limdi NA, Shuldiner AR, Winterstein AG, Johnson JA. Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 11:181-191. [PMID: 29102571 DOI: 10.1016/j.jcin.2017.07.022] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [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] [Received: 05/22/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI). BACKGROUND CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI. METHODS After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights. RESULTS Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60). CONCLUSIONS These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Deepak Voora
- Department of Medicine, Center for Applied Genomics & Precision Medicine, Duke University, Durham, North Carolina
| | - Stephen E Kimmel
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - R David Anderson
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Jorge Alsip
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amer K Ardati
- Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Brigitta C Brott
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lawrence Brown
- Veterans Administration Medical Center, Baltimore, Maryland
| | - Supatat Chumnumwat
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Michael J Clare-Salzler
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - James C Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua C Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Issam S Hamadeh
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Shuko Harada
- Department of Pathology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - William B Hillegass
- Heart South Cardiovascular Group, Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Hines
- Department of Neuropsychology, University of North Dakota, Fargo, North Dakota
| | | | - Lucius A Howell
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda J B Jeng
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Mark D Kelemen
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Yee Ming Lee
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Oyunbileg Magvanjav
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - May Montasser
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - David R Nelson
- College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois; Department of Pharmacy Systems, Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Devon C Nwaba
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Ruth E Pakyz
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Kathleen Palmer
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Josh F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni I Pollin
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Alison H Quinn
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Shawn W Robinson
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Jamie Schub
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Todd C Skaar
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Vindhya B Sriramoju
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Tomasz P Stys
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James M Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nicholas Varunok
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark R Vesely
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Karen E Weck
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Russell A Wilke
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James Willig
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Y Zhao
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nita A Limdi
- Department of Neurology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan R Shuldiner
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida; Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
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25
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Berlacher M, Mastouri R, Philips S, Skaar TC, Kreutz RP. Common genetic polymorphisms of adenosine A2A receptor do not influence response to regadenoson. Pharmacogenomics 2017; 18:523-529. [PMID: 28358597 DOI: 10.2217/pgs-2016-0178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Hemodynamic response to regadenoson varies greatly, and underlying mechanisms for variability are poorly understood. We hypothesized that five common variants of adenosine A2A receptor (ADORA2A) are associated with altered response to regadenoson. METHODS Consecutive subjects (n = 357) undergoing resting regadenoson nuclear stress imaging were enrolled. Genotyping was performed using Taqman-based assays for rs5751862, rs2298383, rs3761422, rs2267076 and rs5751876. RESULTS There was no significant difference in heart rate or blood pressure between different genotypes following regadenoson administration. There was also no significant difference in myocardial ischemia detected by nuclear perfusion imaging as defined by summed difference score, or in self-reported side effects among the genotypes tested. CONCLUSION The common A2A variants studied are not associated with variability in hemodynamic response to regadenoson or variability in detection of ischemia with nuclear perfusion stress imaging.
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Affiliation(s)
- Mark Berlacher
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Ronald Mastouri
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Santosh Philips
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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26
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Kreutz RP, Schmeisser G, Maatman B, Schaffter A, Sinha A, von der Lohe E, Breall JA. Fibrin clot strength measured by thrombelastography and outcomes after percutaneous coronary intervention. Thromb Haemost 2016; 117:426-428. [PMID: 27808346 DOI: 10.1160/th16-10-0496] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/14/2016] [Indexed: 12/19/2022]
Abstract
Supplementary Material to this article is available online at www.thrombosis-online.com.
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Affiliation(s)
- Rolf P Kreutz
- Rolf P. Kreutz, M. D., FACC, FAHA, FSCAI, Associate Professor of Clinical Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1801 N. Senate Blvd., MPC2, ME400, Indianapolis, IN 46202-1228, USA, Tel.: +1 317 962 0500, E-mail:
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27
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Kreutz RP, Breall JA, Sinha A, von der Lohe E, Kovacs RJ, Flockhart DA. Simultaneous administration of high-dose atorvastatin and clopidogrel does not interfere with platelet inhibition during percutaneous coronary intervention. Clin Pharmacol 2016; 8:45-50. [PMID: 27350760 PMCID: PMC4902146 DOI: 10.2147/cpaa.s98790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Reloading with high-dose atorvastatin shortly before percutaneous coronary interventions (PCIs) has been proposed as a strategy to reduce periprocedural myonecrosis. There has been a concern that statins that are metabolized by cytochrome P450 3A4 may interfere with clopidogrel metabolism at high doses. The impact of simultaneous administration of high doses of atorvastatin and clopidogrel on the efficacy of platelet inhibition has not been established. Methods Subjects (n=60) were randomized to receive atorvastatin 80 mg together with clopidogrel 600 mg loading dose (n=28) versus clopidogrel 600 mg alone (n=32) at the time of PCI. Platelet aggregation was measured at baseline, 4 hours after clopidogrel loading dose, and 16–24 hours after clopidogrel loading dose by light transmittance aggregometry using adenosine diphosphate as agonist. Results Platelet aggregation was similar at baseline in both the atorvastatin and the control groups (adenosine diphosphate 10 µM: 57%±19% vs 61%±21%; P=0.52). There was no significant difference in platelet aggregation between the atorvastatin and the control groups at 4 hours (37%±18% vs 39%±21%; P=0.72) and 16–24 hours post-clopidogrel loading dose (35%±17% vs 37%±18%; P=0.75). No significant difference in incidence of periprocedural myonecrosis was observed between the atorvastatin and control groups (odds ratio: 1.02; 95% confidence interval 0.37–2.8). Conclusion High-dose atorvastatin given simultaneously with clopidogrel loading dose at the time of PCI does not significantly alter platelet inhibition by clopidogrel. Statin reloading with high doses of atorvastatin at the time of PCI appears to be safe without adverse effects on platelet inhibition by clopidogrel (ClinicalTrials.gov: NCT00979940).
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey A Breall
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anjan Sinha
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elisabeth von der Lohe
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard J Kovacs
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David A Flockhart
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN, USA
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28
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Eadon MT, Desta Z, Levy KD, Decker BS, Pierson RC, Pratt VM, Callaghan JT, Rosenman MB, Carpenter JS, Holmes AM, McDonald CA, Benson EA, Patil AS, Vuppalanchi R, Gufford BT, Dave N, Robarge JD, Hyder MA, Haas DM, Kreutz RP, Dexter PR, Skaar TC, Flockhart DA. Implementation of a pharmacogenomics consult service to support the INGENIOUS trial. Clin Pharmacol Ther 2016; 100:63-6. [PMID: 26850569 DOI: 10.1002/cpt.347] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/31/2016] [Indexed: 12/19/2022]
Abstract
Hospital systems increasingly utilize pharmacogenomic testing to inform clinical prescribing. Successful implementation efforts have been modeled at many academic centers. In contrast, this report provides insights into the formation of a pharmacogenomics consultation service at a safety-net hospital, which predominantly serves low-income, uninsured, and vulnerable populations. The report describes the INdiana GENomics Implementation: an Opportunity for the UnderServed (INGENIOUS) trial and addresses concerns of adjudication, credentialing, and funding.
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Affiliation(s)
- M T Eadon
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Z Desta
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - K D Levy
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - B S Decker
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - R C Pierson
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - V M Pratt
- Department of Medical and Molecular Genetics, Indiana University, Indianapolis, Indiana, USA
| | - J T Callaghan
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA.,Department of Veterans Affairs, Indianapolis, Indiana, USA
| | - M B Rosenman
- Department of Pediatrics, Northwestern University, Chicago, Illinois, USA
| | - J S Carpenter
- School of Nursing, Indiana University, Indianapolis, Indiana, USA
| | - A M Holmes
- Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - C A McDonald
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - E A Benson
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - A S Patil
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA.,Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA
| | - R Vuppalanchi
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - B T Gufford
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - N Dave
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - J D Robarge
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - M A Hyder
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - D M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA
| | - R P Kreutz
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - P R Dexter
- Regenstrief Institute for Health Care, Indiana University, Indianapolis, Indiana, USA
| | - T C Skaar
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - D A Flockhart
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
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29
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Abstract
AIMS AMPD1 c.34C > T (rs17602729) polymorphism results in AMPD1 deficiency. We examined the association of AMPD1 deficiency and variability of hemodynamic response to regadenoson. SUBJECTS & METHODS Genotyping for c.34C>T was performed in 267 patients undergoing regadenoson cardiac stress testing. RESULTS Carriers of c.34C >T variant exhibited higher relative changes in systolic blood pressure (SBP) compared with wild-type subjects ([%] SBP change to peak: 12 ± 25 vs 5 ± 13%; p = 0.01) ([%] SBP change to nadir: -3 ± 15 vs -7 ± 11%; p = 0.04). Change in heart rate was similar between groups, but side effects were more common in carriers of the variant (+LR = 4.2; p = 0.04). CONCLUSION AMPD1 deficiency may be involved in the modulation of regadenoson's systemic effects.
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Affiliation(s)
- Rayan Saab
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA
| | - Aline N Zouk
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA
| | - Ronald Mastouri
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA
| | - Todd C Skaar
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Clinical Pharmacology Research Institute (R2), Room 402, 950 West Walnut Street, Indianapolis, IN 46202, USA
| | - Santosh Philips
- Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Clinical Pharmacology Research Institute (R2), Room 402, 950 West Walnut Street, Indianapolis, IN 46202, USA
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, MPC2, ME-400, Indianapolis, IN 46202, USA.,Department of Medicine, Division of Clinical Pharmacology, Indiana University School of Medicine, Clinical Pharmacology Research Institute (R2), Room 402, 950 West Walnut Street, Indianapolis, IN 46202, USA
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Sultan A, Kreutz RP. Variations in Clinical Presentation, Risk Factors, Treatment, and Prognosis of Spontaneous Coronary Artery Dissection. J Invasive Cardiol 2015; 27:363-369. [PMID: 26232013] [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: 06/04/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) has been considered a rare cause of acute coronary syndrome (ACS) in younger patients without known cardiovascular risk factors. However, recent studies have reported a higher incidence of SCAD in patients presenting with ACS with use of advanced invasive imaging modalities. In light of increasing awareness, the diagnosis of SCAD has increased significantly. We conducted a single-center retrospective analysis of cases with reported SCAD during a 10-year period between 2003 and 2013. Ten cases of SCAD were identified after review of coronary angiograms and clinical records. Basic demographic details, comorbidities, initial presentation, length of dissection, specific vessels involved in dissection, initial management, subsequent outcome, and incidence of recurrence were documented. All patients were female, with mean age of 42 years. One-third of cases occurred in the peripartum period. All patients presented with acute coronary syndromes. The left anterior descending artery was the predominant vessel involved in 80% of the patients on initial presentation. Out of 10 patients, 6 were managed conservatively, 2 had emergent coronary artery bypass graft, and 2 had percutaneous coronary intervention with placement of stents. Three of the 6 patients undergoing medical management after the initial presentation had recurrence within the same hospitalization.
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Affiliation(s)
| | - Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, ME-400, Indianapolis, IN 46202 USA.
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Kreutz RP, Bitar A, Owens J, Desta Z, Breall JA, von der Lohe E, Sinha A, Vatta M, Nystrom P, Jin Y, Flockhart DA. Factor XIII Val34Leu polymorphism and recurrent myocardial infarction in patients with coronary artery disease. J Thromb Thrombolysis 2015; 38:380-7. [PMID: 24510702 DOI: 10.1007/s11239-014-1059-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 11/24/2022]
Abstract
Factor XIII (FXIII) is necessary for cross linking of fibrin strands and generation of stable fibrin clot. FXIII Val34Leu is a common genetic single nucleotide polymorphism that has been associated with accelerated fibrin stabilization and reduced rate of fibrinolysis. The contribution of Val34Leu to long term risk of recurrent myocardial infarction (MI) in patients with coronary stenting has not been conclusively established. The objective of the study was to examine the effects of Val34Leu on fibrin generation, platelet aggregation, and long term clinical outcomes in patients with coronary artery disease treated with dual antiplatelet therapy. Patients with angiographically documented coronary artery disease who were treated with aspirin and clopidogrel were enrolled (n = 211). Light transmittance aggregometry and plasma fibrin clot formation using thrombelastography (TEG) were determined. Genotyping of Val34Leu was performed using Taqman assay. Clinical events during follow up were recorded. Homozygous carriers of 34 Leu variant had significantly shorter fibrin clot formation time as compared to wild type individuals (TEG K: 1.27 ± 0.3 vs. 1.68 ± 1.1 min, p = 0.011). The Val34Leu variant was associated with gene dose dependent increased risk of MI (log rank, p = 0.002) or occurrence of composite of MI and CV death (log rank, p = 0.005) with highest event rates observed in homozygous carriers of 34 Leu. In summary, FXIII Val34Leu polymorphism was associated with increased rate of fibrin stabilization in homozygous carriers of the variant and may increase risk of recurrent MI and death in patients with angiographically established coronary artery disease treated with dual antiplatelet therapy.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 N. Capitol Ave, ME-400, Indianapolis, IN, 46202, USA,
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Maatman B, Schmeisser G, Owens J, Flockhart D, Kreutz RP. Abstract 597: Plasma Fibrin Clot Strength in Patients With Diabetes Mellitus Measured by Thrombelastography. Arterioscler Thromb Vasc Biol 2015. [DOI: 10.1161/atvb.35.suppl_1.597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with diabetes mellitus (DM) exhibit increased risk of recurrent myocardial infarction. Maximal clot strength measured by thrombelastography (TEG) in whole blood is a risk factor for recurrent ischemic events. We hypothesized that diabetic subjects exhibit increased fibrin clot strength in platelet poor plasma and that extent of glycemic control correlates with maximal fibrin clot strength.
Methods:
Platelet poor plasma samples were obtained from subjects with known or suspected coronary artery disease prior to cardiac catheterization (n=354). Kaolin activated TEG was performed in citrate plasma. Time to fibrin formation (R), clot formation time (K), and maximal fibrin clot strength (MA) measured. Hemoglobin (Hgb) A1C and daily administered insulin doses were recorded.
Results:
Fibrin MA was increased among subjects with DM as compared to non-DM (37.0 ± 8 mm vs. 34.1 ± 8; p<0.001). HgbA1c was significantly correlated with MA (r=0.213; p=0.002). There was no significant correlation between daily insulin dose and MA among patients with insulin dependent DM (r=0.04; p=0.8). In multivariable regression analysis, DM remained significantly associated with plasma MA after adjustment for other clinical variables (p=0.01).
Conclusions:
DM is associated with elevated fibrin clot strength (MA). In addition, increased MA appears to be associated with worse glycemic control as defined by HgbA1C. Our results support that patients with DM, in particular those subjects with poor control, demonstrate more stable fibrin generation than subjects without DM. This may in part contribute to the increased ischemic risk in patients with poorly controlled DM.
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Affiliation(s)
- Benjamin Maatman
- Krannert Institute of Cardiology, Indiana Univ, Indianapolis, IN
| | - Glen Schmeisser
- Krannert Institute of Cardiology, Indiana Univ, Indianapolis, IN
| | - Janelle Owens
- Krannert Institute of Cardiology, Indiana Univ, Indianapolis, IN
| | - David Flockhart
- Div of Clinical Pharmacology, Indiana Univ, Indianapolis, IN
| | - Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana Univ, Indianapolis, IN
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Kreutz RP, Owens J, Lu D, Nystrom P, Jin Y, Kreutz Y, Desta Z, Flockhart DA. Platelet factor XIIIa release during platelet aggregation and plasma clot strength measured by thrombelastography in patients with coronary artery disease treated with clopidogrel. Platelets 2014; 26:358-63. [PMID: 24833046 DOI: 10.3109/09537104.2014.916793] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
It has been estimated that up to half of circulating factor XIIIa (FXIIIa) is stored in platelets. The release of FXIIIa from platelets upon stimulation with adenosine diphosphate (ADP) in patients with coronary artery disease treated with dual antiplatelet therapy has not been previously examined. Samples from 96 patients with established coronary artery disease treated with aspirin and clopidogrel were examined. Platelet aggregation was performed by light transmittance aggregometry in platelet-rich plasma (PRP), with platelet-poor plasma (PPP) as reference, and ADP 5 µM as agonist. Kaolin-activated thrombelastography (TEG) was performed in citrate PPP. PRP after aggregation was centrifuged and plasma supernatant (PSN) collected. FXIIIa was measured in PPP and PSN. Platelet aggregation after stimulation with ADP 5 µM resulted in 24% additional FXIIIa release in PSN as compared to PPP (99.3 ± 27 vs. 80.3 ± 24%, p < 0.0001). FXIIIa concentration in PSN correlated with maximal plasma clot strength (TEG-G) (r = 0.48, p < 0.0001), but not in PPP (r = 0.15, p = 0.14). Increasing quartiles of platelet-derived FXIIIa were associated with incrementally higher TEG-G (p = 0.012). FXIIIa release was similar between clopidogrel responders and non-responders (p = 0.18). In summary, platelets treated with aspirin and clopidogrel release a significant amount of FXIIIa upon aggregation by ADP. Platelet-derived FXIIIa may contribute to differences in plasma TEG-G, and thus, in part, provide a mechanistic explanation for high clot strength observed as a consequence of platelet activation. Variability in clopidogrel response does not significantly influence FXIIIa release from platelets.
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Kreutz RP, Owens J, Jin Y, Nystrom P, Desta Z, Kreutz Y, Breall JA, Li L, Chiang C, Kovacs RJ, Flockhart DA. Cytochrome P450 3A4*22, PPAR-α, and ARNT polymorphisms and clopidogrel response. Clin Pharmacol 2013; 5:185-92. [PMID: 24353446 PMCID: PMC3862586 DOI: 10.2147/cpaa.s53151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Recent candidate gene studies using a human liver bank and in vivo validation in healthy volunteers identified polymorphisms in cytochrome P450 (CYP) 3A4 gene (CYP3A4*22), Ah-receptor nuclear translocator (ARNT), and peroxisome proliferator-activated receptor-α (PPAR-α) genes that are associated with the CYP3A4 phenotype. We hypothesized that the variants identified in these genes may be associated with altered clopidogrel response, since generation of clopidogrel active metabolite is, partially mediated by CYP3A activity. Blood samples from 211 subjects, of mixed racial background, with established coronary artery disease, who had received clopidogrel, were analyzed. Platelet aggregation was determined using light transmittance aggregometry (LTA). Genotyping for CYP2C19*2, CYP3A4*22, PPAR-α (rs4253728, rs4823613), and ARNT (rs2134688) variant alleles was performed using Taqman® assays. CYP2C19*2 genotype was associated with increased on-treatment platelet aggregation (adenosine diphosphate 20 μM; P=0.025). No significant difference in on-treatment platelet aggregation, as measured by LTA during therapy with clopidogrel, was demonstrated among the different genotypes of CYP3A4*22, PPAR-α, and ARNT. These findings suggest that clopidogrel platelet inhibition is not influenced by the genetic variants that have previously been associated with reduced CYP3A4 activity.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indianapolis, Indiana, USA ; Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Janelle Owens
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yan Jin
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Perry Nystrom
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yvonne Kreutz
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Lang Li
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chienwei Chiang
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - David A Flockhart
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Bitar A, Kreutz RP. Role of Thrombelastography (TEG) in Risk Assessment and Guidance of Antithrombotic Therapy in Patients with Coronary Artery Disease. Drug Dev Res 2013. [DOI: 10.1002/ddr.21112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Abbas Bitar
- Krannert Institute of Cardiology; Indiana University School of Medicine; Indianapolis IN USA
| | - Rolf P. Kreutz
- Krannert Institute of Cardiology; Indiana University School of Medicine; Indianapolis IN USA
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Lu D, Owens J, Kreutz RP. Plasma and whole blood clot strength measured by thrombelastography in patients treated with clopidogrel during acute coronary syndromes. Thromb Res 2013; 132:e94-8. [PMID: 23920429 DOI: 10.1016/j.thromres.2013.07.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/27/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Treatment with clopidogrel, a selective platelet P2Y12 receptor antagonist, reduces risk of recurrent ischemic events in patients with acute coronary syndrome (ACS), by limiting platelet aggregation and activation. Stable whole blood clot formation requires activation of platelets, generation of fibrin and final fibrin crosslinks. In this study we intended to compare plasma and whole blood thrombelastography (TEG) measurements in patients during ACS. MATERIALS AND METHODS Whole blood and plasma samples from 32 patients with non-ST segment elevation myocardial infarction (NSTEMI) were collected after administration of clopidogrel. Whole blood and plasma fibrin clot strength (MA) were determined by TEG. Platelet aggregation was determined by light transmittance aggregometry (LTA) using adenosine 5'-diphosphate (ADP), thrombin receptor activation peptide (TRAP), or collagen as agonists. Fibrinogen and C-reactive protein (CRP) concentrations were measured by ELISA. RESULTS Heightened plasma fibrin clot strength was associated with increased platelet reactivity stimulated by ADP (ρ=0.536; p=0.002), TRAP (ρ=0.481; p=0.007), and collagen (ρ=0.538; p=0.01). In contrast to plasma fibrin MA, whole blood MA did not correlate with platelet aggregation. Platelet count was the primary contributor to the difference in thrombin induced whole blood MA and plasma fibrin MA. Increasing levels of CRP were associated with increased plasma fibrin clot strength and platelet reactivity. CONCLUSIONS Our data suggest that inflammation is associated with increased plasma fibrin clot strength and lower platelet inhibition by clopidogrel during ACS. Platelet count is a main contributor to additional contractile force of whole blood TEG as compared to plasma TEG during treatment with clopidogrel.
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Affiliation(s)
- Deshun Lu
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Kreutz RP, Breall JA, Kreutz Y, Owens J, Lu D, Bolad I, von der Lohe E, Sinha A, Flockhart DA. Protease activated receptor-1 (PAR-1) mediated platelet aggregation is dependent on clopidogrel response. Thromb Res 2012; 130:198-202. [PMID: 22459907 PMCID: PMC3965578 DOI: 10.1016/j.thromres.2012.02.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [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: 01/07/2012] [Revised: 02/19/2012] [Accepted: 02/28/2012] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Clopidogrel inhibits ADP mediated platelet aggregation through inhibition of the P2Y12 receptor by its active metabolite. Thrombin induces platelet aggregation by binding to protease activated receptor-1 (PAR-1), and inhibition of PAR-1 has been evaluated in patients treated with clopidogrel to reduce ischemic events after acute coronary syndromes. Residual PAR-1 mediated platelet aggregation may be dependent on extent of clopidogrel response. MATERIAL AND METHODS Platelet aggregation was measured in 55 patients undergoing elective PCI at 16-24 hours after 600 mg clopidogrel loading dose by light transmittance aggregometry using ADP 20 μM and thrombin receptor agonist peptide (TRAP) at 15 μM and 25 μM as agonists. Genomic DNA was genotyped for common CYP2C19 variants. RESULTS Increasing quartiles of 20 μM ADP induced platelet aggregation after clopidogrel loading were associated with increasing levels of TRAP mediated platelet aggregation. Patients in the highest quartile (clopidogrel non-responders) of post treatment ADP aggregation had significantly higher TRAP mediated aggregation than the patients in the lowest quartile (clopidogrel responders) [TRAP 15 μM: 79.6 ± 5% vs. 69.5 ± 8%, p<0.001]. CONCLUSIONS Non-responders to clopidogrel show increased residual platelet aggregation induced by TRAP, whereas clopidogrel responders exhibit attenuated response to TRAP. Addition of PAR-1 antiplatelet drugs may be most effective in patients with reduced clopidogrel response and high residual TRAP mediated platelet aggregation.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Kreutz RP, Nystrom P, Kreutz Y, Miao J, Kovacs R, Desta Z, Flockhart DA, Jin Y. Inhibition of platelet aggregation by prostaglandin E1 (PGE1) in diabetic patients during therapy with clopidogrel and aspirin. Platelets 2012; 24:145-50. [PMID: 22385219 DOI: 10.3109/09537104.2012.661107] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Diabetes mellitus (DM) is associated with increased platelet activation and reduced platelet inhibition by clopidogrel. Prostaglandin E1 (PGE1) stimulates adenyl cyclase activity in platelets and increases cyclic AMP concentrations, which inhibit Ca(2+)release and platelet aggregation induced by P2Y1 receptor activation. PGE1 is included in the VerifyNow P2Y12 assay to suppress P2Y1 induced platelet aggregation. We hypothesized that diabetes mellitus may be associated with altered response to PGE1 in subjects treated with clopidogrel. Subjects with established coronary artery disease who were taking clopidogrel 75 mg daily and aspirin for >14 days were enrolled (n = 96). Diabetic (n = 34) were compared with non-diabetic subjects (n = 62). VerifyNow P2Y12 assay and light transmittance aggregometry (LTA) were performed using ADP as agonist with and without addition of PGE1. Genomic DNA was genotyped for common cytochrome P450 (CYP) 2C19 variants using Taqman assays. Residual on-treatment platelet aggregation induced by 20 µM ADP was not significantly different between subjects with and without DM. Addition of 22 nM and 88 nM PGE1 to 20 µM ADP resulted in a significant reduction of maximal platelet aggregation (MPA). Residual LTA platelet aggregation with PGE1 and VerifyNow P2Y12 platelet reactivity were significantly higher in subjects with DM than those without DM and in carriers of CYP 2C19*2 polymorphism. We conclude that an impaired inhibitory response to PGE1 may contribute to the high platelet reactivity phenotype in subjects with DM treated with clopidogrel. Addition of PGE1 to ADP agonist platelet assays may identify subjects with blunted inhibitory response to prostaglandins and result in a higher proportion of subjects with DM being classified as non-responders.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine , IN 46202, USA.
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Kreutz RP, Nystrom P, Kreutz Y, Miao J, Desta Z, Breall JA, Li L, Chiang C, Kovacs R, Flockhart DA, Jin Y. Influence of paraoxonase-1 Q192R and cytochrome P450 2C19 polymorphisms on clopidogrel response. Clin Pharmacol 2012; 4:13-20. [PMID: 22427735 PMCID: PMC3304338 DOI: 10.2147/cpaa.s27822] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The metabolic activation of clopidogrel is a two-step process. It has been suggested that paraoxonase-1 (PON1) is a rate-limiting enzyme in the conversion of 2-oxo- clopidogrel to an active thiol metabolite. Conflicting results have been reported in regard to (1) the association of a common polymorphism of PON1 (Q192R) with reduced rates of coronary stent thrombosis in patients taking clopidogrel and (2) its effects on platelet inhibition in patient populations of European descent. Methods Blood samples from 151 subjects of mixed racial background with established coronary artery disease and who received clopidogrel were analyzed. Platelet aggregation was determined with light transmittance aggregometry and VerifyNow® P2Y12 assay. Genotyping for cytochrome P450 2C19 (CYP2C19)*2 and *3 and PON1 (Q192R) polymorphisms was performed. Results Carriers of CYP2C19*2 alleles exhibited lower levels of platelet inhibition and higher on-treatment platelet aggregation than noncarriers. There was no significant difference in platelet aggregation among PON1 Q192R genotypes. Homozygous carriers of the wild-type variant of PON1 (QQ192) had similar on-treatment platelet reactivity to carriers of increased-function variant alleles during maintenance clopidogrel dosing, as well as after administration of a clopidogrel 600 mg loading dose. Conclusion CYP2C19*2 allele is associated with impaired platelet inhibition by clopidogrel and high on-treatment platelet aggregation. PON1 (Q192R) polymorphism does not appear to be a significant determinant of clopidogrel response.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
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Kreutz RP, Stanek EJ, Aubert R, Yao J, Breall JA, Desta Z, Skaar TC, Teagarden JR, Frueh FW, Epstein RS, Flockhart DA. Impact of proton pump inhibitors on the effectiveness of clopidogrel after coronary stent placement: the clopidogrel Medco outcomes study. Pharmacotherapy 2011; 30:787-96. [PMID: 20653354 DOI: 10.1592/phco.30.8.787] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE To investigate the potential impact of proton pump inhibitors (PPIs) on the effectiveness of clopidogrel in preventing recurrent ischemic events after percutaneous coronary intervention (PCI) with stent placement. DESIGN Population-based, retrospective cohort study. DATA SOURCE National medical and pharmacy benefit claims database comprising approximately 19 million members. PATIENTS A total of 16,690 patients who had undergone PCI with stent placement and who were highly adherent to clopidogrel therapy alone (9862 patients) or to clopidogrel with a PPI (6828 patients) between October 1, 2005, and September 30, 2006. MEASUREMENTS AND MAIN RESULTS The primary end point was the occurrence of a major adverse cardiovascular event during the 12 months after stent placement. These events were defined as hospitalization for a cerebrovascular event (stroke or transient ischemic attack), an acute coronary syndrome (myocardial infarction or unstable angina), coronary revascularization (PCI or coronary artery bypass graft), or cardiovascular death. A composite event rate was compared between patients who received clopidogrel alone and those who received concomitant clopidogrel-PPI therapy. Baseline differences in covariates were adjusted by using Cox proportional hazards models. In the 9862 patients receiving clopidogrel alone, 1766 (17.9%) experienced a major adverse cardiovascular event compared with 1710 patients (25.0%) who received concomitant clopidogrel-PPI therapy (adjusted hazard ratio 1.51, 95% confidence interval 1.39-1.64, p<0.0001). Similar associations of increased risk were observed for each PPI studied (omeprazole, esomeprazole, pantoprazole, and lansoprazole). CONCLUSION Concomitant use of a PPI and clopidogrel compared with clopidogrel alone was associated with a higher rate of major adverse cardiovascular events within 1 year after coronary stent placement.
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Affiliation(s)
- Rolf P Kreutz
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
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Kreutz RP, Alloosh M, Mansour K, Neeb Z, Kreutz Y, Flockhart DA, Sturek M. Morbid obesity and metabolic syndrome in Ossabaw miniature swine are associated with increased platelet reactivity. Diabetes Metab Syndr Obes 2011; 4:99-105. [PMID: 21660293 PMCID: PMC3107692 DOI: 10.2147/dmso.s17105] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) and type 2 diabetes mellitus in humans are associated with increased platelet activation and hyperreactivity of platelets to various agonists. Ossabaw swine develop all the hallmarks of MetS including obesity, insulin resistance, hypertension, dyslipidemia, endothelial dysfunction, and coronary artery disease when being fed excess calorie atherogenic diet. We hypothesized that Ossabaw swine with MetS would exhibit increased platelet reactivity compared with lean pigs without MetS. MATERIALS AND METHODS Ossabaw swine were fed high caloric, atherogenic diet for 44 weeks to induce MetS (n = 10) and were compared with lean controls without MetS that had been fed normal calorie standard diet (n = 10). Light transmittance aggregometry was performed using adenosine diphosphate (ADP), collagen, thrombin, and arachidonic acid (AA) at different concentrations. Dose response curves and EC50 were calculated. Glucose tolerance testing and intravascular ultrasound study of coronary arteries were performed. RESULTS MetS pigs compared with lean controls were morbidly obese, showed evidence of arterial hypertension, elevated cholesterol, low-density lipoprotein/high-density lipoprotein, and triglycerides, and insulin resistance. Platelets from MetS pigs were more sensitive to ADP-induced platelet aggregation than leans (EC50: 1.83 ± 1.3 μM vs 3.64 ± 2.2 μM; P = 0.02). MetS pigs demonstrated higher platelet aggregation in response to collagen than lean pigs (area under the curve: 286 ± 74 vs 198 ± 123; P = 0.037) and a trend for heightened response to AA (AUC: 260 ± 151 vs 178 ± 145; P = 0.13). No significant difference was found for platelet aggregation in response to thrombin. CONCLUSIONS MetS in Ossabaw swine is associated with increased reactivity of platelets to ADP and collagen. The Ossabaw swine may be a practical, large animal model for the study of certain aspects of platelet pathophysiology and examine vascular devices in a metabolic environment comparable to humans with MetS.
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Affiliation(s)
- Rolf P Kreutz
- Krannert Institute of Cardiology, Indiana University School of Medicine, IN, USA.
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Tantry US, Bliden KP, Suarez TA, Kreutz RP, Dichiara J, Gurbel PA. Hypercoagulability, platelet function, inflammation and coronary artery disease acuity: Results of the Thrombotic RIsk Progression (TRIP) Study. Platelets 2010; 21:360-7. [DOI: 10.3109/09537100903548903] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Gurbel PA, Bliden KP, Kreutz RP, Dichiara J, Antonino MJ, Tantry US. The link between heightened thrombogenicity and inflammation: Pre-procedure characterization of the patient at high risk for recurrent events after stenting. Platelets 2009; 20:97-104. [DOI: 10.1080/09537100802687666] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Dichiara J, Bliden KP, Tantry US, Chaganti SK, Kreutz RP, Gesheff TB, Kreutz Y, Gurbel PA. Platelet function measured by VerifyNow identifies generalized high platelet reactivity in aspirin treated patients. Platelets 2007; 18:414-23. [PMID: 17763150 DOI: 10.1080/09537100701206824] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [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: 01/29/2023]
Abstract
Selected aspirin treated patients may exhibit high platelet reactivity to agonists other than arachidonic acid. This study aimed to determine whether the VerifyNow identifies generalized high platelet reactivity supported by correlations with other established methods that stimulate platelets with various agonists. Stable outpatients with coronary artery disease (n = 110) were treated with aspirin in a two 3 x 3 Latin square design (81, 162 and 325 mg/day for 4 weeks each). VerifyNow (arachidonic acid (AA) cartridge); light transmittance aggregometry; thrombelastography; PFA-100; flow cytometry; PlateletWorks; and urinary 11- dehydro thromboxane levels were measured. Multianalyte profiling measured fibrinogen and von Willebrand factor (vWF). Patients with >or=550 ARU by VerifyNow had increased 5 mM AA-, 5 microM ADP-, and 2 microg/mL collagen-induced platelet aggregation compared to patients with <550 ARU (p <or= 0.001). The highest ADP- and collagen-induced aggregation was present in the upper quartile by VerifyNow (p < 0.05). Fibrinogen or vWF levels did not differ between VerifyNow quartiles. Patients with high platelet reactivity to arachidonic acid identified by VerifyNow also exhibit increased reactivity to other important platelet agonists that is independent of fibrinogen and vWF levels. These data suggest that VerifyNow may identify a generalized high platelet reactivity phenotype.
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Affiliation(s)
- Joseph Dichiara
- Sinai Center for Thrombosis Research, Baltimore, Maryland 21215, USA
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Gurbel PA, Bliden KP, Guyer K, Cho PW, Zaman KA, Kreutz RP, Bassi AK, Tantry US. Platelet reactivity in patients and recurrent events post-stenting: results of the PREPARE POST-STENTING Study. J Am Coll Cardiol 2005; 46:1820-6. [PMID: 16286165 DOI: 10.1016/j.jacc.2005.07.041] [Citation(s) in RCA: 524] [Impact Index Per Article: 27.6] [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: 04/14/2005] [Revised: 07/08/2005] [Accepted: 07/11/2005] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We investigated the relation of high ex vivo platelet reactivity, rapid fibrin generation, and high thrombin-induced clot strength to postdischarge ischemic events in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND High platelet reactivity and rapid fibrin generation may affect the incidence of ischemic events after PCI. However, limited data is available to link these ex vivo markers to the occurrence of events. METHODS We measured platelet reactivity to adenosine diphosphate (ADP) by light transmittance aggregometry (LTA) in patients undergoing PCI (n = 192). Clot strength, a measure of thrombin-induced fibrin and platelet interactions, and the time to initial fibrin generation, a marker of thrombin activity, were measured by thrombelastography. The relation of these measurements to ischemic event occurrence was prospectively examined over six months. RESULTS A total of 100% and 84% of patients were on aspirin and clopidogrel therapy, respectively, at the time of the initial event. Posttreatment ADP-induced aggregation by LTA (63 +/- 12% vs. 56 +/- 15%, p = 0.02) and clot strength (MA) were higher (74 +/- 5 mm vs. 65 +/- 4 mm, p < 0.001) and time to initial fibrin generation was shorter (4.3 +/- 1.3 min vs. 5.9 +/- 1.5 min, p < 0.001) in patients with events (n = 38). The event rates in the highest quartiles of LTA and MA were 32% and 58%, respectively. CONCLUSIONS High platelet reactivity and clot strength, and rapid fibrin formation are novel risk factors for ischemic events after PCI. Clot strength is more predictive than ADP-induced platelet aggregation and may explain the occurrence of events despite treatment with cyclooxygenase-1 and P2Y12 inhibitors.
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Affiliation(s)
- Paul A Gurbel
- Sinai Center for Thrombosis Research, Baltimore, Maryland 21215, USA.
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Kreutz RP, Bliden KP, Tantry US, Gurbel PA. Viral respiratory tract infections increase platelet reactivity and activation: an explanation for the higher rates of myocardial infarction and stroke during viral illness. J Thromb Haemost 2005; 3:2108-9. [PMID: 16102122 PMCID: PMC7166489 DOI: 10.1111/j.1538-7836.2005.01474.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 04/07/2005] [Indexed: 11/29/2022]
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