Pharmacokinetics, mass balance, and metabolism of [14C]vicagrel, a novel irreversible P2Y12 inhibitor in humans

Vicagrel, a novel irreversible P2Y₁₂ receptor inhibitor, is undergoing phase III trials for the treatment of acute coronary syndromes in China. In this study, we evaluated the pharmacokinetics, mass balance, and metabolism of vicagrel in six healthy male Chinese subjects after a single oral dose of 20 mg [¹⁴C]vicagrel (120 µCi). Vicagrel absorption was fast (T_max = 0.625 h), and the mean t_1/2 of vicagrel-related components was ~38.0 h in both plasma and blood. The blood-to-plasma radioactivity AUC_inf ratio was 0.55, suggesting preferential distribution of drug-related material in plasma. At 168 h after oral administration, the mean cumulative excreted radioactivity was 96.71% of the dose, including 68.03% in urine and 28.67% in feces. A total of 22 metabolites were identified, and the parent vicagrel was not detected in plasma, urine, or feces. The most important metabolic spot of vicagrel was on the thiophene ring. In plasma pretreated with the derivatization reagent, M9-2, which is a methylated metabolite after thiophene ring opening, was the predominant drug-related component, accounting for 39.43% of the radioactivity in pooled AUC_0-8 h plasma. M4, a mono-oxidation metabolite upon ring-opening, was the most abundant metabolite in urine, accounting for 16.25% of the dose, followed by M3-1, accounting for 12.59% of the dose. By comparison, M21 was the major metabolite in feces, accounting for 6.81% of the dose. Overall, renal elimination plays a crucial role in vicagrel disposition, and the thiophene ring is the predominant metabolic site.

Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization

Background

While use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non–ST‐segment elevation myocardial infarction patients who did not undergo coronary revascularization.

Methods and Results

We included unrevascularized non–ST‐segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry‐GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease (CAD; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD. Two‐year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all‐cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability‐weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD, and 34.7% (n=4915) had angiography with CAD. Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI]: 0.99 [0.93–1.06]), angiography without CAD (1.04 [0.74–1.47]), and angiography with CAD (1.12 [1.00–1.25], P_interaction=0.20).

Conclusions

We found no association between discharge clopidogrel use and long‐term risk of major adverse cardiac events among older, unrevascularized non–ST‐segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.

De-escalation therapy after acute coronary syndrome: is it reasonable to switch from prasugrel (or ticagrelor) to clopidogrel early?

Dual antiplatelet treatment (DAPT) is the treatment of choice to prevent atherothrombotic events in patients with acute coronary syndrome (ACS) treated with percutaneous interventions (PCIs). The availability of different P2Y12 inhibitors set the stage for costum made DAPT, as to achieve the highest profile of safety and efficacy. The de-escalation therapy for the newer and more powerful antiplatelet drugs, such as ticagrelor and prasugrel, to clopidogrel, is a strategy for patients with recent ACS, unfit for continuing DAPT for their high risk of bleeding, or side effects, or socio-economic reasons, but without a prohibitive ischaemic risk. There is a need for compelling clinical evidences able to provide the clinical cardiologist with the necessary information to decide the best antiplatelet strategy for each individual patient.

Safety of cangrelor and transition to oral P2Y12 inhibitors in patients undergoing percutaneous coronary intervention: the ARCANGELO study

Aims

Cangrelor is the only intravenous P2Y12 inhibitor available. Safety, efficacy, and transitioning from cangrelor to oral P2Y12 inhibitors were recorded in patients with acute coronary syndrome (ACS). The ARCANGELO study aims to assess the safety of cangrelor on bleeding and the effects of the transition to oral P2Y12 inhibitors in a real-world setting according to the European Medical Agency's requirement.

Methods and results

Adult patients with ACS undergoing percutaneous coronary intervention (PCI) receiving cangrelor were included in the study. Patients were followed for 30 days. Incidence of bleeding events, major adverse cardiac events, and transition strategy to oral P2Y12 were recorded. Among 1004 ACS patients undergoing PCI, 995 (99.1%) were eligible for the analysis; 597 (60.0%) of them had ST-segment elevation myocardial infarction. A total of 925 (93.1%) patients underwent PCI by radial catheter access, and 972 (97.2%) received drug-eluting stents. All eligible patients received bolus and cangrelor infusion between 2 and 4 h in 95% of the cases. A total of 730 patients (73.4%) received ticagrelor, 127 (12.8%) prasugrel, and 138 (13.9%) clopidogrel as transition therapy. Bleeding, according to Bleeding Academic Research Consortium (BARC) criteria, within 30 days post-PCI occurred in 5.2% of patients (95% confidence interval: 3.9-6.8%); 0.5% experienced a moderate (BARC 3), and all others mild (BARC 1-2) bleeding events. Major adverse cardiac events occurred in 14 (1.4%) patients, principally all-cause mortality (n = 6 patients) and myocardial infarction (n = 7 patients).

Conclusion

The use of cangrelor in ACS patients undergoing PCI and the transition strategy to P2Y12 inhibitors are confirmed as safe and effective in daily practice.

P2Y12 receptor inhibitor plus aspirin versus aspirin treated within 24 hours of acute noncardioembolic ischemic stroke or TIA: Meta-analysis

BACKGROUND/PURPOSE

Antiplatelet therapy is the cornerstone for acute ischemic stroke or transient ischemic attack (TIA). The purpose of this study was to conduct a meta-analysis to assess the efficacy and safety of P2Y12 receptor inhibitor plus aspirin versus aspirin alone treated within 24 h after acute noncardioembolic ischemic stroke or TIA.

METHODS

We search Pubmed, EMBASE, CENTRAL and clinicaltrials.gov from January 1966 to January 2021. We included randomized trials which compared P2Y12 receptor inhibitor plus aspirin versus aspirin alone. Relative risk (RR) with 95% confidence (CI) was used as a measure of P2Y12 receptor inhibitor plus aspirin versus aspirin. The primary efficacy endpoint was recurrent stroke and the primary safety endpoint was severe bleeding.

RESULTS

The search identified 5 randomized trials comparing P2Y12 receptor inhibitor plus aspirin and aspirin with 21,808 individuals enrolled. Pooled results from these trials showed that P2Y12 receptor inhibitor plus aspirin compared with aspirin was associated with a lower risk of recurrent stroke (RR 0.75, 95% CI 0.68 to 0.83). Ticagrelor plus aspirin compared with aspirin was associated with increased risk of severe bleeding (RR 3.98, 95% CI 1.74 to 9.10) and intracranial hemorrhage (RR 3.32, 95% CI 1.33 to 8.25), whereas clopidogrel plus aspirin vs. aspirin had similar hemorrhagic risk.

CONCLUSION

P2Y12 receptor inhibitor plus aspirin vs aspirin given within 24 h after acute noncardioembolic ischemic stroke or TIA reduces the risk of subsequent stroke. However, the risk of severe bleeding, including intracranial hemorrhage, was higher with ticagrelor plus aspirin vs aspirin.

PROSPERO ID

CRD42020203730.

Ticagrelor Does Not Protect Against Endothelial Ischemia-Reperfusion Injury in Patients With Coronary Artery Disease

BACKGROUND

Ticagrelor is a recommended P2Y₁₂ receptor inhibitor after acute coronary syndrome (ACS). Its superiority has been suggested to rely on pleiotropic effects beyond platelet inhibition. Experimental studies indicate that ticagrelor may protect from ischemia-reperfusion injury but no data are available from such studies on patients. This study aimed to determine if chronic ticagrelor treatment protects against endothelial ischemia-reperfusion injury in patients with a previous ACS.

METHODS

Patients with a previous ACS were studied with flow mediated dilatation of the left brachial artery to determine the degree of endothelial ischemia-reperfusion injury before and after discontinuation of ticagrelor treatment, which had been continuous since 1 year. Each patient underwent 3 identical examinations. The first examination (Visit A) was at the end of ticagrelor treatment and the following 2 (Visit B and C) were after cessation of this treatment with an interval of 2 to 4 weeks.

RESULTS

Ischemia and reperfusion induced significant impairment of endothelial function at all 3 occasions (absolute decline in flow mediated dilatation 3.0% ± 0.7 at Visit A (P < 0.001), 1.9% ± 0.9 at Visit B (P < 0.05) and 1.9% ± 0.4 at Visit C (P < 0.0001)). However, there was no difference in the degree of endothelial ischemia-reperfusion injury or baseline endothelial function between the visits.

CONCLUSION

Chronic ticagrelor treatment in patients 1 year after an ACS does not protect against endothelial ischaemia-reperfusion injury. Nor is it associated with better basal endothelial function compared to after discontinuation of treatment.

Abbreviated dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 receptor inhibitor, is a standard post-percutaneous coronary intervention (PCI) treatment to reduce thrombosis and ischemic events. However, the optimal DAPT duration remains unclear, with concerns about bleeding risks associated with long-term potent P2Y12 inhibitors. This systematic review and meta-analysis investigates the safety and efficacy of shortened DAPT regimens.

METHODS

A comprehensive search of PubMed, Scopus, and EMBASE identified randomized controlled trials (RCTs) comparing conventional DAPT (≥ 12 months) and abbreviated DAPT (≤ 3 months) post-PCI. Primary outcomes were 1-year all-cause mortality and bleeding, assessed using the Bleeding Academic Research Consortium (BARC) classification. Secondary outcomes included cardiovascular mortality, non-fatal myocardial infarction (MI), stroke, and major adverse cardiovascular events (MACE). Risk of bias was assessed with the Cochrane tool, and meta-analyses used random-effects models.

RESULTS

Forty studies involving 54,233 participants were included. Abbreviated DAPT significantly reduced all-cause mortality (RR: 0.90, 95%CI: 0.82-0.98) and bleeding (BARC 3 or 5: RR: 0.77, 95%CI: 0.60-0.97). No significant differences were observed in cardiovascular mortality, stroke, non-fatal MI, revascularization, or in-stent thrombosis. Subgroup analyses showed lower mortality with 1-month DAPT and reduced bleeding in patients with high bleeding risk, acute coronary syndrome (ACS), and complex PCI.

CONCLUSIONS

Abbreviated DAPT post-PCI is associated with lower all-cause mortality and bleeding without compromising ischemic protection, supporting its use in specific patient populations. Individualized DAPT durations should be considered to balance bleeding and ischemic risks.

Comparison of Short-Term DAPT and Long-Term DAPT on the Prognosis of PCI Patients: A Meta-Analysis of Randomized Controlled Trials

Background

Dual antiplatelet therapy (DAPT) is the primary medication for patients after percutaneous coronary intervention (PCI). However, the best DAPT duration is still controversial. This systematic review and meta-analysis aims to assess the safety and effectiveness of short-term (3-6 months) DAPT compared to long-term (12 months) DAPT.

Methods

We searched PubMed, Embase, Cochrane Library, and Web of Science systematically for all the randomized controlled trials (RCTs) which compared the different strategies for DAPT in patients undergoing PCI within ten years prior to January 2021. Major bleeding and any bleeding were identified as the safe endpoints. All causes of death, cardiac death, myocardial infarction, definite/probable stent thrombosis, target vessel revascularization, and stroke were identified as the efficacy endpoints. The hazard ratio (HR) and 95% confidence interval (CI) in each study were abstracted.

Results

Overall, 11 trials and 24,242 patients were included in this meta-analysis with 15-month median follow-up time. Short-term DAPT was related to reduced risks of major bleeding (HR 0.65, 95% CI 0.48-0.89) and any bleeding (HR 0.64, 95% CI 0.53-0.79). No obvious differences in any of the other endpoints were observed. In acute coronary syndrome (ACS) patients with drug-eluting stents (DES), short-term compared with long-term DAPT was related to a decreased risk of major bleeding (HR 0.57, 95% CI 0.37-0.87) without significant increasing in the risks of any bleeding and ischemic endpoints. Furthermore, short-term DAPT followed by P2Y12 receptor inhibitor monotherapy appreciably lowered the risk of major bleeding (HR 0.64, 95% CI 0.42-0.96) and any bleeding (HR 0.58, 95% CI 0.36-0.93). There were no obvious differences concerning death between the different strategies for DAPT.

Conclusions

After PCI with DES, short-term DAPT is safer than long-term DAPT, and is not inferior in effectiveness, even in ACS patients. P2Y12 receptor inhibitor monotherapy following short-term DAPT is also related to a decreased risk of bleeding and may be an alternative anti-platelet strategy.

P2Y12 Inhibitor-Based Single Antiplatelet Therapy Versus Conventional Dual Antiplatelet Therapy After Newer-Generation Drug-Eluting Stent Implantation in Chronic and Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

P2Y12 inhibitor-based single antiplatelet therapy (SAPT) after drug-eluting stent implantation reduces major bleeding without increasing the risk of major adverse cardiovascular and cerebral events compared with 12-month dual antiplatelet therapy (DAPT). The differential effects of P2Y12 inhibitor monotherapy compared with conventional DAPT in patients with chronic coronary syndromes versus acute coronary syndromes (ACS) remain uncertain.

METHODS AND RESULTS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing oral P2Y12 inhibitor-based SAPT after ≤3 months DAPT versus 12-month DAPT after newer-generation drug-eluting stent implantation. Patients were categorized based on baseline presentation (chronic coronary syndromes versus ACS). The co-primary end points were major bleeding and major adverse cardiovascular and cerebral events, a composite of all-cause death, myocardial infarction, or ischemic stroke. A total of 43 945 (ACS, 28 360, 65%) patients from 7 randomized controlled trials were included. At a median follow-up of 12 months, P2Y12 inhibitor-based SAPT was associated with a lower risk of major bleeding (risk ratio [RR], 0.63 [95% CI, 0.48-0.82]; P<0.001) compared with 12-month DAPT. The risk of major bleeding was significantly lower among patients with ACS (RR, 0.55 [95% CI, 0.40-0.75]; P<0.001). Compared with standard DAPT, P2Y12 inhibitor-based SAPT was associated with a similar risk of major adverse cardiovascular and cerebral events (RR, 0.98 [95%CI, 0.87-1.11]; P=0.74) among patients with chronic coronary syndromes and ACS. There was no significant interaction between treatment effect and baseline presentation.

CONCLUSIONS

Compared with 12-month DAPT, P2Y12 inhibitor-based SAPT after newer-generation drug-eluting stent implantation is associated with a lower risk of major bleeding without increasing the risk of major adverse cardiovascular and cerebral events, a difference primarily driven by patients with ACS.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023239341.

Reassessing the role of aspirin in patients with coronary artery disease

INTRODUCTION

Recent data question the use of aspirin as a bedrock of antiplatelet therapy in patients with arterial diseases. There are controversies regarding the efficacy of aspirin therapy with respect to specific demographic characteristics, dose and formulations, benefit in primary prevention, and duration in secondary prevention. Importantly, to balance the ischemic benefits and the risk of excessive bleeding following a coronary event, recent studies have investigated strategies to discontinue aspirin therapy and continue with P2Y12 receptor inhibitor monotherapy. However, the precise time when to discontinue aspirin is still unresolved.

AREAS COVERED

Evidence from recent studies evaluating the role of aspirin in primary and secondary prevention studies was collected from a selective literature search. In this review, the authors discuss current recommendations, large-scale studies of aspirin therapy, controversies, and potential future opportunities for aspirin therapy.

EXPERT OPINION

With the new evidence showing lower bleeding risk with aspirin-free strategies in both primary and secondary prevention studies, the role of aspirin is being revaluated with P2Y12 receptor inhibitor monotherapy. The potential benefits of novel aspirin formulations and alternative delivery methods, such as inhaled aspirin, are undergoing much-needed investigation with the goal of optimizing care for a wide range of patients.

Review of the Ticagrelor Trials Evidence Base

Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.