Efficacy and Safety of the Use of Non-vitamin K Antagonist Oral Anticoagulants in Patients with Ischemic Heart Disease: A Meta-Analysis of Phase III Randomized Trials

BACKGROUND

There are conflicting published data on non-vitamin K antagonist oral anticoagulants (NOACs), with varying evidence of benefit or harm in acute coronary syndrome (ACS) and non-ACS cohorts. To explore the efficacy and safety of NOAC use in patients with ischemic heart disease (IHD), we conducted a meta-analysis of phase III randomized controlled trials (RCTs).

METHODS

We systematically searched the Cochrane Library, PubMed, and Embase databases. A random-effect model was selected to pool the effect measurement estimates (hazard ratios [HRs] and 95% confidence intervals [CIs]).

RESULTS

Three RCTs with 39,492 enrolled IHD patients were included. Compared with placebo, NOACs were associated with reduced risks of major adverse cardiac events (MACE) (HR 0.83, 95% CI 0.76-0.90), cardiovascular death (HR 0.82, 95% CI 0.72-0.93), and myocardial infarction (HR 0.87, 95% CI 0.78-0.97) accompanied by increased risks of major bleeding (HR 2.46, 95% CI 1.42-4.26), but not fatal bleeding (HR 1.35, 95% CI 0.76-2.39) or intracranial hemorrhage (HR 2.19, 95% CI 0.91-5.27). Subgroup analysis revealed that NOACs were associated with an increased risk of major bleeding in patients who received dual antiplatelet therapy compared with patients who received single antiplatelet therapy (3.01, 1.82-4.98 vs. 1.66, 1.37-2.03; P for interaction 0.03) and patients with ACS compared with patients with non-ACS (3.27, 2.16-4.95 vs. 1.66, 1.36-2.02; P for interaction 0.004).

CONCLUSIONS

In patients with IHD, NOACs confer protection against thrombosis-related complications, but at the cost of an increased hazard of major bleeding. NOACs plus a single antiplatelet drug seem to be a good choice for patients with IHD.

Prevention of atherothrombotic events in patients with diabetes mellitus: from antithrombotic therapies to new-generation glucose-lowering drugs

Diabetes mellitus is an important risk factor for a first cardiovascular event and for worse outcomes after a cardiovascular event has occurred. This situation might be caused, at least in part, by the prothrombotic status observed in patients with diabetes. Therefore, contemporary antithrombotic strategies, including more potent agents or drug combinations, might provide greater clinical benefit in patients with diabetes than in those without diabetes. In this Consensus Statement, our Working Group explores the mechanisms of platelet and coagulation activity, the current debate on antiplatelet therapy in primary cardiovascular disease prevention, and the benefit of various antithrombotic approaches in secondary prevention of cardiovascular disease in patients with diabetes. While acknowledging that current data are often derived from underpowered, observational studies or subgroup analyses of larger trials, we propose antithrombotic strategies for patients with diabetes in various cardiovascular settings (primary prevention, stable coronary artery disease, acute coronary syndromes, ischaemic stroke and transient ischaemic attack, peripheral artery disease, atrial fibrillation, and venous thromboembolism). Finally, we summarize the improvements in cardiovascular outcomes observed with the latest glucose-lowering drugs, and on the basis of the available evidence, we expand and integrate current guideline recommendations on antithrombotic strategies in patients with diabetes for both primary and secondary prevention of cardiovascular disease.

DAPT Plus Cilostazol is Better Than Traditional DAPT or Aspirin Plus Ticagrelor as Elective PCI for Intermediate-to-Highly Complex Cases: Prospective, Randomized, PRU-Based Study in Taiwan

PURPOSE

Current treatment guidelines do not recommend different antiplatelet treatments for patients in different coronary risk categories; nor do they consider ethnic differences in responses to individual drugs.

OBJECTIVES

We performed a prospective, single-blind, randomized, comparative study of Taiwanese patients with stable angina and scheduled stent implantation for intermediate-to-highly complex coronary lesions and compared the platelet reactivity unit (PRU) levels and 24-month outcomes of groups receiving three different antiplatelet treatments.

METHODS

Patients (N = 334) were randomized into three treatment groups (aspirin + clopidogrel, aspirin + ticagrelor, or aspirin + clopidogrel + cilostazol) for 6 months of treatment and were then switched to aspirin only. PRU levels were determined 24 h, 7 days, and 1 month after stent implantation. Clinical outcomes and adverse events were recorded over 24 months.

RESULTS

Clopidogrel treatment reached full effect after 1 month. Ticagrelor decreased PRU levels more than did clopidogrel but often to levels that increased the risk of hemorrhage. The addition of cilostazol to clopidogrel decreased PRU levels earlier and more strongly than clopidogrel alone but not as strongly as did ticagrelor. Ticagrelor treatment caused fewer major adverse cardiovascular events (MACEs) and more episodes of minor bleeding than the other two treatments.

CONCLUSIONS

Clopidogrel appears safer than ticagrelor in Taiwanese patients with stable angina after stent implantation for intermediate-to-highly complex coronary lesions. The addition of cilostazol to clopidogrel may provide a more rapid decrease in PRU to therapeutic levels without increasing the risk of hemorrhage.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02101411.

High and low on-treatment platelet reactivity to P2Y12 inhibitors in a contemporary cohort of acute coronary syndrome patients undergoing percutaneous coronary intervention

INTRODUCTION

There is compelling evidence supporting the association between high on-treatment platelet reactivity (HPR) and low on-treatment platelet reactivity (LPR) to clopidogrel with atherothrombotic and bleeding events, respectively. However, it is uncertain if current cutoff values should be used in prasugrel- or ticagrelor-treated subjects. The objective of this analysis was to evaluate the pharmacodynamic (PD) efficacy of P2Y₁₂ antagonists in a contemporary real-world population.

MATERIALS AND METHODS

This PD study included 988 patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) and receiving dual therapy with aspirin and a P2Y₁₂ inhibitor (clopidogrel, prasugrel or ticagrelor). Platelet function was assessed at day 1 and day 30 post-PCI by VerifyNow P2Y12 assay, multiple electrode aggregometry and vasodilator-stimulated phosphoprotein (VASP) assay.

RESULTS

Clopidogrel-treated patients (n = 324) had greater platelet reactivity than those receiving ticagrelor (n = 469) or prasugrel (n = 195) at both time points (p < 0.001 for all comparisons). No difference between ticagrelor and prasugrel was observed at day 1 with the VerifyNow P2Y12 assay (51.5 ± 2.8 vs. 42.7 ± 3.5 PRUs; p = 0.298), whereas ticagrelor achieved greater platelet inhibition at day 30 (48.1 ± 2.5 vs. 89.2 ± 4.2 PRUs; p < 0.001). Similar results were obtained with the VASP assay. Both prasugrel and ticagrelor had markedly lower HPR rates than clopidogrel and very high rates of LPR at both time points.

CONCLUSIONS

Prasugrel and ticagrelor displayed more potent and consistent PD effects than clopidogrel in ACS patients undergoing PCI, with a trend towards greater platelet inhibition with ticagrelor during the maintenance phase of therapy compared to prasugrel.

Long-term dual antiplatelet therapy: pharmacological and clinical implications

: Patients experiencing an acute coronary syndrome are exposed to an increased residual risk of recurrent coronary events. Dual antiplatelet therapy (DAPT) is highly effective in preventing atherothrombotic complications in patients with previous myocardial infarction and current guidelines recommend the prescription of DAPT for at least 12 months in all patients experiencing an acute event. However, recent findings demonstrated that long-term DAPT (over 12 months) is related to a better outcome in patients at high risk, suggesting the use of a long-term DAPT to achieve a better clinical outcome. The choice of DAPT duration is still a difficult issue and a personalized approach to the patients is mandatory to manage both the residual ischemic risk and the risk of bleeding events.The aim of this review is to analyze the pharmacological characteristics of available antiplatelet agents and to revise the use of DAPT in clinical practice, focusing on the benefits of a long-term approach.

[Troponins as biomarkers for myocardial injury and myocardial infarction]

Elevation of cardiac troponins above the 99th percentile of a healthy reference population is established as a marker for myocardial cell damage and is crucial for the diagnosis of myocardial infarction. In addition, corresponding clinical evidence of acute myocardial ischemia i.e. symptoms, changes in the electrocardiogram (ECG), wall motion abnormalities or suggestive angiographic findings are required for the diagnosis of myocardial infarction. Using modern highly sensitive assays myocardial infarction can be detected more frequently and earlier. On the other hand myocardial infarction can be ruled out with a higher diagnostic accuracy. Cardiac troponins are specific for myocardial cell damage but not for myocardial infarction and can be elevated in numerous other disease states. In these cases myocardial injury can be diagnosed independently of myocardial ischemia. Typical dynamics with rise and fall of troponin levels can distinguish acute myocardial injury (e. g. pericarditis/myocarditis and pulmonary embolism) from chronic myocardial injury (e. g. cardiomyopathy). Clinically, highly sensitive troponin assays are currently recommended in addition to the 0/3 h and 0/1 h algorithms for rapid inclusion or exclusion of myocardial infarction.

Prevalence of Atrial Fibrillation and use of Oral Antithrombotic Therapy in Patients with Acute Coronary Syndrome

PURPOSE

To assess the prevalence of atrial fibrillation (AF) and use of antithrombotic agents in adult patients with acute coronary syndrome (ACS).

MATERIALS AND METHODS

We consecutively enrolled all ACS patients (n=1155) who were hospitalized in two Moscowbased percutaneous coronary intervention centers (each center performs over 500 PCIs a year) between October 2017 and February 2018. AF was diagnosed in 204 patients (17.7%). The risk of thromboembolic complications was assessed using the CHA2DS2-VASc Score. The risk of hemorrhagic complications was assessed using the HAS-BLED Score. The data were processed using StatSoft Statistica 10.0 and IBM SPSS Statistics v.23 software.

RESULTS

The prevalence of diagnosed AF was 13.6%, while the prevalence of undiagnosed AF was 4.1%. Of the 179 discharged patients with AF, only 2 had a low risk of ischemic stroke (IS). One hundred and fifty patients (83.8%) eligible for oral anticoagulant therapy received oral anticoagulants. Patients with diagnosed AF were administered oral anticoagulants (OACs) significantly more often than patients with undiagnosed AF [125 (91.9%) vs. 25 (58.1%), р&lt;0.001]. Novel oral anticoagulants (NOACs) were administered four times more often than vitamin K antagonists [120 (80.0%) vs. 29 (19.3%), р&lt;0.001]. Rivaroxaban was used in 51.3% of cases. Of the 29 patients treated with warfarin, only 3 (10.3%) achieved the target international normalized ratio (INR) at discharge. Of the 107 patients who underwent percutaneous coronary intervention (PCI), 77 patients (80%) received an OAC and two antiplatelet agents (with 74% receiving this three-agent therapy for one month), 11 patients (10.3%) received an OAC and an antiplatelet agent, and 18 patients (16.8%) received two antiplatelet agents. The only antiplatelet agent used as part of the three-agent therapy was clopidogrel. The three-agent therapy without PCI was administered in 43.1% of cases.

CONCLUSION

We found that the prevalence of AF in patients with ACS was high. The fact that doctors administered NOACs suggests that they are aware of the need to use these agents to prevent thromboembolic complications in AF patients.

Dual antiplatelet therapy after TAVR: A drop in the bucket?

Current guidelines recommend a three- to six-months dual antiplatelet therapy (DAPT) in patients undergoing transcatheter aortic valve replacement (TAVR) or to continue with oral anticoagulant agents (OAC) if already indicated before procedure. However, recent studies showed that treatment with aspirin has the same efficacy of DAPT but it was associated with a significant reduction of major bleeding. Furthermore, half of cerebrovascular events, occurring >24 h after procedure, may be related to new onset of atrial fibrillation or to subclinical leaflets thrombosis and they may be prevented by use of OAC rather than antiplatelet therapy. In absence of very high bleeding risk and of recent percutaneous coronary intervention, the use of OAC over SAPT or DAPT might theoretically be considered in patients undergoing TAVR waiting for results of ongoing clinical trials.

Clopidogrel versus Ticagrelor for Secondary Prevention after Coronary Artery Bypass Grafting

We sought to evaluate the outcomes of postoperative three-month dual antiplatelet therapy in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) following off-pump coronary artery bypass grafting (OPCAB) with exclusively arterial grafts. Between 2013–2016, dual antiplatelet therapy (DAPT) with either aspirin + clopidogrel (ASA + CPD group, n = 100) or aspirin + ticagrelor (ASA + TCG group, n = 169) was prescribed postoperatively in 269 NSTE-ACS patients after total arterial OPCAB. Patients with indications for other oral anticoagulants were excluded from the study. Three-month DAPT was completed in 259 patients (96%); ASA + CPD group (n = 94) vs. ASA + TCG group (n = 165). A one-to-one propensity score matching was performed. Unadjusted comparison between the groups showed no significant difference in overall survival (P = 0.253) and composite outcome of major adverse cerebrovascular and cardiovascular event (MACCE) and major bleeding (P = 0.276). The rate of freedom from composite outcome at one year in the ASA + CPD and ASA + TCG groups was 91 ± 3% and 93 ± 2%, respectively. In multivariable analysis, being in the ASA + TCG group did not increase the risk of the composite outcome of MACCE and major bleeding (P = 0.972, hazard ratio: 1.0, 95% confidence interval: 0.4–2.3). Propensity score-matched comparison (76 pairs) showed no significant difference in the overall survival (P = 0.423) and composite outcome between the groups (P = 0.442). In the setting of exclusive arterial grafting, post-OPCAB three-month DAPT showed acceptable outcomes in patients with NSTE-ACS. There was no significant difference in overall survival or composite outcome of MACCE and major bleeding between the ASA + CPD and ASA + TCG groups.

Triple Antithrombotic Therapy vs. Double Antithrombotic Therapy: One Scenario, 8 Questions, Many Conclusions

In patients with atrial fibrillation undergoing percutaneous coronary intervention with the placement of stents, a triple antithrombotic therapy is empirically established, which consists of a combination of dual antithrombotic therapy (aspirin plus a P2Y12 inhibitor) and an oral anticoagulant agent. This choice is guided by the desirable result of reducing cerebrovascular and coronary ischemic events. However, there is an unwelcome outcome: an increased incidence of bleeding. On this matter, in 2018, a North American Perspective Update was published, about a year later it was followed by the publication of the European focus update on the dual antiplatelet therapy. After analysing the main differences between these two consensus documents, this review aims at examining the major studies on which they are based on, as a starting point to define the foundation of new trials that can help shed light on this prominent topic.

Competing risks of major bleeding and thrombotic events with prasugrel-based dual antiplatelet therapy after stent implantation - An observational analysis from BASKET-PROVE II

BACKGROUND

Dual antiplatelet therapy (DAPT) prevents thrombotic events after coronary stent implantation but may induce bleedings, specifically in elderly patients. However, a competitive risk analysis is lacking.

OBJECTIVES

To assess the determinants of major bleeding and the balance between the competing risks of major bleeding and thrombotic events during prasugrel-based DAPT after stent implantation.

METHODS

Overall, 2,291 patients randomized to drug-eluting or bare metal stents and treated with prasugrel 10mg/day for 1 year were followed over 2 years for major bleeding (BARC 3/5) and thrombotic events (cardiac death, myocardial infarction, definitive/probable stent thrombosis). Prasugrel dose was reduced to 5mg in patients >75 years and/or <60kg. Predictors of major bleeding and competing risks of major bleeding and thrombotic events were assessed.

RESULTS

Two-year rates of major bleeding and thrombotic events were 2.9% and 9.0%, respectively. The only independent predictor of major bleeding was age (hazard ratio per year increase 1.05 [1.02,1.07], p<0.001). The relationship between major bleeding and age was non-linear, with lowest hazard ratios at 57 years and an exponential increase only above 65 years. In contrast, the relationship between thrombotic events and age was linear and continuously increasing with older age. While the competing risk of thrombotic events was higher than that of major bleeding in younger patients, the two risks were similar in older patients. After discontinuation of prasugrel, bleeding events leveled off in all patients, while thrombotic events continued to increase.

CONCLUSIONS

In prasugrel-based DAPT, age is the strongest risk factor for major bleeding, increasing exponentially >65 years. In younger patients, thrombotic events represent a higher risk than bleeding, while thrombotic and bleeding risks were similar in older patients. Important clinical implications relate to prasugrel dose in the elderly, duration of DAPT and the competing risk balance necessitating individualized treatment decisions.

Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention: A nationwide Korean population-based study

Background

We investigated the recent 10-year trends in the number of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in relation to prescription patterns of antithrombotic therapy.

Methods

We analyzed the annual prevalence of PCI and patterns of antithrombotic therapy after PCI, including antiplatelets and oral anticoagulants (vitamin K antagonists and non-vitamin K antagonist oral anticoagulants [NOACs]), in patients with AF between 2006 and 2015 by using the Korean National Health Insurance Service database. Independent factors associated with triple therapy (oral anticoagulant plus dual antiplatelet) prescription were assessed using multivariable logistic regression analysis.

Results

The number of patients with AF undergoing PCI increased gradually from 2006 (n = 2,140) to 2015 (n = 3,631) (p_trend<0.001). In 2006, only 22.7% of patients received triple therapy after PCI although 96.2% of them were indicated for anticoagulation (CHA₂DS₂-VASc score ≥2). The prescription rate of triple therapy increased to 38.3% in 2015 (p_trend<0.001), which was mainly attributed to a recent increment of NOAC-based triple therapy from 2013 (17.5% in 2015). Previous ischemic stroke or systemic embolism, old age, hypertension, and congestive heart failure were significantly associated with a higher triple therapy prescription rate, whereas previous myocardial infarction, PCI, and peripheral arterial disease were associated with triple therapy underuse.

Conclusions

From 2006 to 2015, the number of patients with AF undergoing PCI and the prescription rate of triple therapy increased gradually with a recent increment of NOAC-based antithrombotic therapy from 2013. Previous myocardial infarction, peripheral artery disease, and PCI were associated with underuse of triple therapy.

Secondary prevention therapies in acute coronary syndrome and relation to outcomes: observational study

Objective

To ascertain the use of secondary prevention medications and cardiac rehabilitation after an acute coronary syndrome (ACS) and the impact on 2-year outcomes.

Methods

CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) is a prospective, observational registry of 41 Australian hospitals. A representative sample of 6859 patients with an ACS and 6 months’ follow-up on 31 May 2016 were included. The main outcome measure was use of ≥75% of indicated medications (≥4/5 (or ≥3/4 if contraindicated) of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker, beta-blocker, lipid-lowering therapy, aspirin and other antiplatelet). Major adverse cardiovascular events (MACE) included myocardial infarction, stroke or cardiovascular death.

Results

The mean age was 65±13 years, 29% were women, and the mean Global Registry of Acute Coronary Events (GRACE) score was 106±30. At discharge, 92% were on aspirin, 93% lipid-lowering therapy, 78% beta-blocker, 74% ACE/angiotensin receptor blocker and 73% a second antiplatelet; 89% were taking ≥75% of medications at discharge, 78% at 6 months and 66% at 2 years. At 6 months, 38% attended cardiac rehabilitation, 58% received dietary advice and 32% of smokers reported quitting. Among 1896 patients followed to 2 years, death/MACE was less frequent among patients on ≥75% vs <75% of medications (8.3% vs 13.9%; adjusted OR 0.75, 95 % CI 0.56 to 0.99), and was less frequent in patients who attended versus who did not attend cardiac rehabilitation (4.6% vs 13.4%; adjusted OR 0.44, 95% CI 0.31 to 0.62).

Conclusions

Use of secondary prevention therapies diminishes over time following an ACS. Patients receiving secondary prevention had decreased rates of death and MACE at 2 years.

[Acute coronary syndrome without ST-elevation (NSTE-ACS)]

The timing of an invasive diagnosis and treatment strategy in patients with an acute coronary syndrome without ST-elevation (NSTE-ACS) depends on the patient's risk profile. In addition to the clinical symptoms, ST/T alterations in the resting ECG as well as an increase and kinetics of troponin are of crucial importance in this setting. For the majority of patients the highly sensitive troponin enables a rapid rule in or rule out strategy of a non-ST-segment elevation myocardial infarction (NSTEMI) with a 0/3 h algorithm. An even faster 0/1 h algorithm is increasingly being used; however, troponin only helps to identify patients with NSTEMI. Troponin-negative patients can still suffer from unstable angina pectoris. A dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASS) and an ADP receptor antagonist should be initiated in the acute phase and continued for 12 months, irrespective of the initial treatment strategy, e.g. percutaneous coronary intervention (PCI), bypass surgery or conservative treatment. In patients with a high bleeding risk a duration of 6 months only may be considered, whereas in patients with a high risk of ischemia the DAPT might be prolonged for up to 36 months.

Percutaneous coronary interventions with the Absorb Bioresorbable vascular scaffold in real life: 1-year results from the FRANCE ABSORB registry

BACKGROUND

Several randomized studies have shown that bioresorbable vascular scaffold (BVS) technology is associated with an increased risk of stent thrombosis.

AIM

This study aimed to assess the rates of adverse outcomes at 1 year in patients treated with the Absorb BVS (Abbott Vascular, Santa Clara, CA, USA), using data from a large nationwide prospective multicentre registry (FRANCE ABSORB).

METHODS

All patients receiving the Absorb BVS in France were included prospectively in the study. Predilatation, optimal sizing and postdilatation were recommended systematically. The primary endpoint was a composite of cardiovascular death, myocardial infarction and target lesion revascularization at 1 year. Secondary endpoints were scaffold thrombosis and target vessel revascularization at 1 year.

RESULTS

A total of 2072 patients at 86 centres were included: mean age 55±11 years; 80% men. The indication was acute coronary syndrome (ACS) in 49% of cases. Predilatation and postdilatation were done in 93% and 83% of lesions, respectively. At 1 year, the primary endpoint occurred in 3.9% of patients, the rate of scaffold thrombosis was 1.5% and the rate of target vessel revascularization was 3.3%. In a multivariable analysis, diabetes and total Absorb BVS length>30mm were independently associated with the occurrence of the primary endpoint, whereas oral anticoagulation and total Absorb BVS length>30mm were independently associated with occurrence of scaffold thrombosis.

CONCLUSIONS

The Absorb BVS was implanted in a relatively young population, half of whom had ACS. Predilatation and postdilatation rates were high, and 1-year outcomes were acceptable.

Evaluation of Drug Therapy and Adherence to It in Patients after Acute Coronary Syndrome in Real Clinical Practice (Results of One Year Observation)

Aim. To study the prescribed drug therapy, as well as adherence to it in patients with acute coronary syndrome (ACS) in real clinical practice within a year after the index event. Material and methods. The study included 327 patients who were in hospital treatment with ACS: 199 patients (60.9%) with unstable angina (UA) and 128 (39.1%) – with acute myocardial infarction (AMI). The prescribed treatment and adherence to therapy were evaluated within 12 months after the coronary event. Therapy prescribed to patients was compared with current clinical guidelines for the treatment of patients with ACS. Results. 67% of patients completed the clinical study Adherence to prescribed medication within 12 months after ACS was maximal for ACE inhibitors/angiotensin receptor blockers (83.6%), dual antiplatelet therapy (79.9%) and β-blockers (78.1%), and minimal for lipid-lowering drugs (statins; 61.6%). A significant decrease in adherence was revealed in 6 and 12 months from the initiation of therapy. Significantly higher level of adherence to DAT was found in patients with AMI compared with patients with UA (p<0.05). When analyzing the frequency of occurrence of endpoints, it was found that patients who did not adhere to treatment significantly more often had hospitalizations due to UA (15.1% vs 7.4%; p<0.05), AMI (16.9% vs 8.1%; p<0.05), death from cardiovascular causes (13% vs 10.4%; p<0.05). Conclusion. Therapy prescribed at the outpatient stage in patients with ACS in the Rostov Region corresponds to the modern clinical recommendations. Six months after hospital discharge adherence to drug therapy in patients is reduced, which requires more careful outpatient monitoring during this period. In patients who are not adherent to treatment, cardiovascular complications are significantly more frequent.

P2Y₁₂ Receptor Inhibitors in the Treatment of Patients with Acute Coronary Syndrome and Percutaneous Coronary Intervention: Possibilities of Prasugrel

The possibilities of P2Y12 receptor inhibitors application in the treatment of patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) are discussed in the article. The results of 4 registries in which a comparative analysis of the efficacy and safety of prasugrel with clopidogrel or ticagrelor was performed, as well as of all 3 P2Y12-receptor inhibitors among themselves, are considered in detail. The feasibility of replacing clopidogrel to prasugrel during the inpatient treatment of patients with ACS and PCI was evaluated additionally in the MULTIPRAC registry. The results of the registries demonstrate that the use of prasugrel in patients with ACS and PCI is associated with a significant reduction in the risk of ischemic complications and mortality with an acceptable risk of bleeding. At the same time, prasugrel was more effective and safer than clopidogrel and at least was non-inferior to ticagrelor, and according to some registries, even surpasses it in a number of indicators.

 

Dual Anticoagulant/Antiplatelet Activity of Polyphenolic Grape Seeds Extract

Because of the side-effects of commonly used anti-platelet and anticoagulant drugs, investigations into plant substances with similar activities are very common. Based on our own studies in recent years, we estimate that it is possible to use natural compounds to both inhibit coagulation pathway enzymes and to reduce blood platelets’ activation. As such, in our current study we wanted to verify the anti-platelet and anticoagulant properties of grape seed extract (GSE) using in vitro models. During our analysis, the following parameters were analyzed: Coagulation times, thromboelastometry assays (coagulation time, clot formation time and maximum clot firmness), aggregation of platelets and phosphorylation of vasodilator-stimulated phosphoprotein (VASP). Adenosine diphosphate (ADP)-induced aggregation was lower in GSE 7.5 µg/mL as well as in GSE 15.0 µg/mL. A similar dependence was observed in VASP assays for GSE 7.5 µg/mL and GSE 15 µg/mL. The effect on plasma coagulation tests was distinct only with GSE 15 µg/mL. All of the thromboelastometry variables were statistically significant with 15.0 µg/mL GSE concentration. Our results show, for the first time, the multi-potential effect of grape seed extract on coagulation systems, and clearly suggest that grape seed extract could be considered a promising nutraceutical in the prevention of cardiovascular thrombotic events caused by different mechanisms.

Current status of acute myocardial infarction in Korea

Coronary artery disease, especially acute myocardial infarction (AMI), is a leading cause of death in the Asia-Pacific region. The Korea Acute Myocardial Infarction Registry (KAMIR) is the first nationwide, prospective, multicenter registry of Korean patients with AMI. Since the KAMIR first began in November 2005, more than 70,000 patients have been enrolled, and 230 papers have been published (as of October 2018). Moreover, published data from the KAMIR have revealed different characteristics from those of Western AMI registries regarding risk factors, interventional strategies, and clinical outcomes. As a result, the KAMIR study has improved the outcomes of percutaneous coronary intervention and reduced mortality. We propose the use of the KAMIR score in the prediction of 1-year mortality. Using data from the KAMIR, we provide an overview of the current status of AMI in Korea, including trends in demographic characteristics, risk factors, medications, treatment strategies, and clinical outcomes.

Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials

BACKGROUND

Triple therapy (TT) that includes oral anticoagulation and dual antiplatelet therapy is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). The randomized clinical trials (RCTs) comparing the effectiveness and safety of TT compared to double therapy (DT), which consists of an oral anticoagulation and one of the P2Y12 inhibitors, have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes. To compare the clinical outcomes of TT and DT, we performed this meta-analysis of RCTs.

METHODS

Electronic search of PubMed, EMBASE and Cochrane CENTRAL databases was performed for RCTs comparing TT and DT in patients who were on oral anticoagulation (Vitamin K antagonist or non-vitamin K antagonist oral anticoagulant) who underwent PCI. All-cause and cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and TIMI major and minor bleeding were the major outcomes.

RESULTS

An analysis of 5 trials including 10,592 total patients showed that TT, compared to DT, resulted in non-significant difference in risk of all-cause [odds ratio (OR); 1.14;95% confidence interval (CI):(0.80-1.63); P = 0.46) and cardiovascular mortality [1.43(0.58-3.36); P = 0.44], MI [0.88 (0.64-1.21); P = 0.42], stroke [1.10(0.75-1.62); P = 0.63] and ST [0.82(0.46-1.45); P = 0.49]. TT, compared to DT resulted in higher risk of TIMI major bleeding [1.61(1.09-2.37); P = 0.02], TIMI minor bleeding [1.85(1.23-2.79); P = 0.003] and TIMI major and minor bleeding [1.81 (1.38-2.38); P < 0.0001; I2 = 52%].

CONCLUSION

Compared to DT, the patients receiving TT are at a higher risk of major and minor bleeding with no survival benefit or impact on thrombotic outcomes.

Evolving paradigms in antithrombotic therapy for anticoagulated patients undergoing coronary stenting

A sizable proportion of coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) with stent implantation have an indication for treatment with oral anticoagulant therapy (OAC). The coexistence of atrial fibrillation (AF) and the need for PCI expose patients to a higher risk of developing thrombotic complications, and a multitargeted antithrombotic treatment strategy, addressing both platelet- and coagulation-mediated triggering mechanisms of thrombosis, is necessary for ensuring full protection from ischemic hazards. The increased bleeding risk identified with triple antithrombotic therapy has driven the search for alternative treatment modalities and pharmacological combination strategies aimed at achieving an optimal balance between safety and efficacy in this complex clinical scenario. Over a short time period, the paradigms surrounding the management of patients undergoing PCI who require OAC have substantially evolved. In this review, we summarize and critically evaluate the results of recent randomized clinical trials investigating the pharmacological management of patients who, in addition to antiplatelet therapy, have an indication for OAC treatment before or at the time of a PCI procedure.

Ticagrelor for Asian patients with acute coronary syndrome in real-world practice: A systematic review and meta-analysis of observational studies

OBJECTIVE

We aimed to assess the efficacy and safety of ticagrelor compared to clopidogrel in Asian patients with acute coronary syndrome (ACS) in real-world practice.

METHODS

PubMed, Web of Science and Scopus databases were searched systematically to obtain relevant Asian observational studies.

RESULTS

The meta-analysis included six studies with 27959 participants. Compared with clopidogrel, ticagrelor was significantly beneficial in prevention of major adverse cardiac events (MACCEs) (OR=0.62; 95% CI: 0.46-0.83, I2=69%, p=0.001) mainly driven by reducing stroke (OR=0.62; 95% CI: 0.49-0.78, I2=0%, p<0.001). No differences were found between ticagrelor and clopidogrel in the risk of cardiovascular mortality (OR=0.66; 95% CI: 0.41-1.06, I2=0%, p=0.09), target vessel revascularization (OR=0.53; 95% CI: 0.21-1.35, I2=82%, p=0.18), major bleeding (OR=1.11; 95% CI: 0.62-2.00, I2=75%, p=0.73), and net adverse clinical and cerebral events (OR=0.76; 95% CI: 0.55-1.04, I2=78%, p=0.09). However, ticagrelor significantly increased the incidence of major/minor (OR=1.73; 95% CI: 1.36-2.21, I2=0%, p<0.001) and minor bleeding (OR=1.73; 95% CI: 1.29-2.32, I2=0%, p<0.001). Sensitivity analyses did not find consistent effect of ticagrelor on prevention of all-cause death and myocardial infarction.

CONCLUSION

This meta-analysis suggested that ticagrelor might reduce the risk of MACCEs mainly by reducing stroke in Asian patients with ACS without increasing the rates of major bleeding. Ticagrelor did not show a significant effect on other parts of MACCEs. Considerable increase in the risk of major/minor and minor bleeding was observed in ticagrelor compared with clopidogrel users. Further high-quality studies are required to support these findings.

Platelet Reactivity And Circulating Platelet-Derived Microvesicles Are Differently Affected By P2Y12 Receptor Antagonists

Background: Platelet-derived microvesicles (PMVs), shed from platelet surface membranes, constitute the majority of circulating microvesicles and have been implicated in procoagulant, pro-inflammatory and pro-atherosclerotic effects. Our aim was to compare plasma PMVs numbers in relation to platelet reactivity during dual antiplatelet therapy (DAPT) with various P2Y₁₂ adenosine diphosphate (ADP) receptor antagonists. Methods: In pre-discharge men treated with DAPT for an acute coronary syndrome, plasma PMVs were quantified by flow cytometry on the basis of CD62P (P-selectin) and CD42 (glycoprotein Ib) positivity, putative indices of PMVs release from activated and all platelets, respectively. ADP-induced platelet aggregation was measured by multiple-electrode aggregometry. Results: Clinical characteristics were similar in patients on clopidogrel (n=16), prasugrel (n=10) and ticagrelor (n=12). Platelet reactivity was comparably reduced on ticagrelor or prasugrel versus clopidogrel (p<0.01). Compared to clopidogrel-treated patients, CD42⁺/CD62P⁺ PMVs counts were 3-4-fold lower in subjects receiving ticagrelor (p=0.001) or prasugrel (p<0.05), while CD42⁺ PMVs were significantly reduced on ticagrelor (by about 6-fold, p<0.001), but not prasugrel (p=0.3). CD42⁺/CD62P⁺ PMVs numbers correlated positively to the ADP-induced aggregation on clopidogrel (p<0.01) or prasugrel (p<0.05), which was absent in ticagrelor users (p=0.8). CD42⁺ PMVs counts were unrelated to platelet reactivity (p>0.5). Conclusions: Higher antiplatelet potency of prasugrel and ticagrelor versus clopidogrel is associated with decreased plasma CD42⁺/CD62P⁺ PMVs numbers. However, in contrast to thienopyridines, the association of reduced CD42⁺/CD62P⁺ PMVs counts with ticagrelor use appears independent of its anti-aggregatory effect. Despite similar platelet-inhibitory activity of ticagrelor and prasugrel, only the treatment with ticagrelor seems associated with lower total PMVs release. Our preliminary findings may suggest a novel pleiotropic effect of ticagrelor extending beyond pure anti-aggregatory properties of the drug.

Long-Term Use of Antiplatelet Therapy in Real-World Patients with Acute Myocardial Infarction: Insights from the PIPER Study

The aim of this study was to assess long-term drug adherence and prognosis in real-world patients discharged on dual-antiplatelet therapy (DAPT) after acute myocardial infarction (AMI). A retrospective cohort analysis using administrative databases kept by eight local health units was performed. DAPT exposure (defined as ≥ 2 prescriptions), adherence, and the occurrence of major adverse events (MACE) were analyzed during a 36-month follow-up. The analysis included 11,101 patients who were discharged alive with a primary diagnosis of AMI. Of these, 5,919 patients (53.31%) were discharged on DAPT without a diagnosis of cancer or anemia, without transient DAPT discontinuation, and represented the study population. DAPT discontinuation occurred in 2,200 patients (37.2%) and in 1,995 (33.7%) after the first 6 and 12 months, respectively, whereas 423 patients (7.1%) were still on DAPT after 36 months. Patients who maintained DAPT up to 12 months had a significantly lower overall mortality, compared with patients who discontinued DAPT after 6 months. Exposure to DAPT at 3 years was associated with reduced all-cause mortality (hazard ratio [HR]: 0.067, 95% confidence interval [CI]: 0.027–0.162, p  < 0.001) and reduced recurrent AMI (HR: 0.02, 95% CI: 0.003–0.173, p  < 0.001). In conclusion, this study shows that prolonged DAPT over 12 months is maintained in a relevant number of patients after AMI. However, adherence to antiplatelet therapy in first 12 months after AMI is still unsatisfactory and efforts to enhance patients' compliance are warranted. Exposure to prolonged DAPT at 3 years seems to be associated with a significant reduction in all-cause mortality and AMI.

Do We Need Potent Intravenous Antiplatelet Inhibition at the Time of Reperfusion During ST-Segment Elevation Myocardial Infarction?

Acute myocardial infarction (MI) is still a large source of morbidity and mortality worldwide. Although early reperfusion therapy has been prioritized in the modern era of percutaneous coronary intervention and thrombolysis, attempts at incremental improvements in clinical outcomes by reducing MI size have not been successful so far. Herein, we review the studies that have evaluated immediate-onset antiplatelet therapy as attempts to improve meaningful clinical outcomes in ST-segment elevation MI (STEMI). Unfortunately, many of the adjunctive pharmacotherapies have proven to be disappointing. Recent studies performed in the background of routine oral administration of P2Y₁₂ adenosine receptor inhibitors, which may take several hours to take full effect, and aspirin have largely shown no improvement in outcomes, despite an earlier onset of antiplatelet activity of the investigative agents. Further progress in improving outcomes during STEMI may depend on exploring therapeutics that modulate the pathophysiology of microvascular damage during ischemia-reperfusion injury, a phenomenon whose effects evolve over hours to days. We speculate that the dynamic nature of the no-reflow phenomenon may be an explanation for these disappointing results with the intravenous antiplatelet agents. We hope that appreciation for what has not worked in this domain may direct future research efforts to focus on novel pathways. Myocardial ischemia and reperfusion injury are very much still a lingering issue. Despite significant improvements in door-to-balloon times, rates of in-hospital mortality for STEMI remain unchanged. Outcomes following successfully reperfused STEMI are likely determined by the initial size of myocardial necrosis (ie, cardiomyocyte death during the period of ongoing ischemia), patency of the infarct-related epicardial coronary artery, possible reperfusion injury, the microvascular no-reflow phenomenon, and adverse remodeling after infarction.

Effect of Potent P2Y12 Inhibitors on Ventricular Arrhythmias and Cardiac Dysfunction in Coronary Artery Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies have shown that P2Y12 receptor inhibitors might prevent ventricular arrhythmias and cardiac dysfunction in patients with coronary artery disease. However, few studies have focused on comparison of the efficacy of novel oral potent P2Y12 receptor inhibitors with clopidogrel on these outcomes.

METHODS AND RESULTS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) that were published in electronic databases of MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials, and ClinicalTrials.gov before June 20, 2018. We compared the effect of prasugrel and ticagrelor with clopidogrel on outcomes of ventricular tachycardia (VT), ventricular fibrillation (VF), heart failure (HF), and cardiogenic shock (CS). Data were combined using both the fixed-effects models and the random-effects models, and the heterogeneity was assessed with the I 2 statistic. Nine RCTs (6 with prasugrel and 3 with ticagrelor) with 45,227 patients were included. Patients receiving prasugrel were associated with a lower risk of combined VT and VF (rate ratio [RR]: 0.72, 95% confidence interval [CI]: 95% CI: 0.52-0.99, p=0.043), as well as combined HF and CS (RR: 0.81, 95% CI: 0.70-0.94, p=0.005), compared with clopidogrel. Patients receiving ticagrelor were also associated with a reduced risk of VT and VF (RR: 0.85, 95% CI: 0.72-1.02, p=0.077), although without statistical significance, but not of HF and CS (RR: 0.96, 95% CI: 0.81-1.13, p=0.620).

CONCLUSIONS

This meta-analysis of RCTs shows that, compared with clopidogrel, novel oral P2Y12 inhibitors, especially prasugrel, might have better effect on improving ventricular rhythm and cardiac function.

Contemporary management of patients referring to cardiologists one to three years from a myocardial infarction: The EYESHOT Post-MI study

AIMS

To describe the contemporary management by cardiologists of patients after an episode of myocardial infarction (MI).

METHODS

The EYESHOT Post-MI was a prospective, observational, nationwide study aimed to evaluate the management of patients referring to cardiologists 1 to 3 years from the last MI event.

RESULTS

Over a 3-month period, 1633 consecutive patients [median 22 (IQR 15-28) months from MI] were enrolled: 1028 (63.0%) at the second and 605 (37.0%) at the third year from MI. During the 12 months prior to enrolment, the majority of patients received a transthoracic echocardiogram (60% and 54%), followed by coronary angiography (24% and 16%, in the second and third year from MI groups, respectively). At the time of enrolment, the majority of patients were prescribed on statins (93%) and beta-blockers (82%), without significant differences between the 2 groups. A dual antiplatelet therapy (DAPT) was used more frequently among patients presenting during the second compared to the third year from MI (40% vs 24%; p < 0.0001). At multivariable analysis, the time interval from last MI (2 vs 3 years: OR 2.27; 95% CI 1.79-2.88; p < 0.0001) and a previous percutaneous coronary intervention with multiple stents (OR 3.46; 95% CI 2.19-5.47; p < 0.0001) resulted as the major independent predictors of DAPT persistence at the time of enrolment.

CONCLUSIONS

This contemporary registry provides unique insights into the current management of post-MI patients and represents an opportunity to further improve the long-term treatment of this high-risk population.

Nintedanib in Idiopathic Pulmonary Fibrosis: Practical Management Recommendations for Potential Adverse Events

Idiopathic pulmonary fibrosis (IPF) is a fatal lung disease with a dismal survival rate of only 3 years and no curative pharmacological therapy. The recent approval of 2 anti-fibrotic drugs (nintedanib and pirfenidone) that slow disease progression has provided some hope for patients. However, effectively managing anti-fibrotic treatment can be a challenge due to tolerability issues, the presence of pulmonary and extra-pulmonary comorbidities, and the need for concomitant medications in many patients. In general, making clear evidence-based decisions can be difficult for physicians because patients with comorbidities are often excluded from clinical trials. Since currently anti-fibrotic drugs are the only effective therapeutics capable of slowing disease progression, it is imperative that all treatment options are thoroughly evaluated and exhausted in each individual, irrespective of complicating factors, to permit the best outcome for the patient. In this review, we present data from clinical trials, post hoc analyses, post-marketing surveillance, and real-world studies that are relevant to the management of nintedanib treatment. In addition, we also provide practical recommendations developed by a multidisciplinary panel of experts for the management of nintedanib treatment in patients with IPF associated complications and those experiencing gastrointestinal side effects.

Platelet reactivity in patients with chronic kidney disease undergoing percutaneous coronary intervention

This study aimed to evaluate the platelet reactivity in real-world patients with different chronic kidney disease (CKD) stages after percutaneous coronary intervention (PCI), and to examine whether high residual platelet reactivity (HRPR) is associated with higher incidence of adverse cardiovascular events in a 2-year follow up. A total of 10 724 consecutive patients receiving DAPT with aspirin and clopidogrel after PCI throughout 2013 were enrolled. We applied modified thromboelastography (mTEG) in 6745 patients. Kaplan-Meier analysis and Cox proportional regression analysis were applied to illustrate end points for patients. The prevalence of HRPR for adenosine diphosphate (ADP) was higher in patients with CKD3-5 than patients with CKD1-2 (47.0% vs. 37.3%, p = 0.002), but not for arachidonic acid (AA). No significant difference was observed for MACCE between patients with or without HRPR for ADP (HR 1.004, 95%CI: 0.864-1.167, p = 0.954). Patients with HRPR for ADP was associated with less bleeding events than patients without HRPR for ADP (HR 0.795, 95%CI: 0.643-0.982, p = 0.034). In this large cohort of real-world patients after PCI, the deterioration of renal function was linked to HRPR for ADP. HRPR was not associated with MACCE in patients with CKD in a 2-year follow up. Bleeding risks were significantly lower in PCI patients with versus without HRPR for ADP.

Arterial events in cancer patients-the case of acute coronary thrombosis

Patients with cancer are at high risk for both venous and arterial thrombotic complications. A variety of factors account for the greater thrombotic risk, including the underlying malignancy and numerous cancer-directed therapies. The occurrence of an acute thrombotic event in patients with cancer is associated with substantial morbidity and mortality. Acute coronary syndrome (ACS) represents a particularly important cardiovascular complication in cancer patients. With cardio-vascular risk factors becoming more prevalent in an aging cancer population that is surviving longer, questions pertaining to the appropriate management of vascular toxicity are likely to assume even greater value in the coming years. In this article, we review the current understanding of ACS in patients with cancer. The predisposition to thrombosis in a malignant host and the cancer treatments most commonly associated with vascular toxicity are reviewed. Risk prediction and management strategies are discussed, and discrepancies in the clinical evidence are highlighted.