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Welsh RC, Shavadia JS, Zheng Y, Tyrrell BD, Leung R, Bainey KR. Ticagrelor or clopidogrel dual antiplatelet therapy following a pharmacoinvasive strategy in ST-segment elevation myocardial infarction. Clin Cardiol 2021; 44:1543-1550. [PMID: 34405422 PMCID: PMC8571547 DOI: 10.1002/clc.23716] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 01/30/2023] Open
Abstract
Objectives To describe and evaluate outcomes in STEMI patients sustained on clopidogrel compared to those switched to ticagrelor following fibrinolysis. Background World‐wide, many STEMI patients cannot achieve timely PCI and therefore require fibrinolysis. Although comparable 30‐day and 1‐year safety was shown with clopidogrel or ticagrelor in the TREAT study, there is paucity of long‐term outcomes in pharmacoinvasive treated STEMI. Methods We conducted an observational cohort study evaluating consecutive pharmacoinvasive STEMI patients treated in a network, comparing those switched to ticagrelor to those sustained on clopidogrel. The primary efficacy composite was one‐year all‐cause death, recurrent myocardial infarction, and stroke with major bleeding and intracranial hemorrhage (ICH) as the safety outcomes. Multivariable Cox regression model was used to examine the association between P2Y12 inhibitor and outcomes with inverse probability weighting. Results Of 1426 pharmacoinvasive STEMI patients, 28% (n = 396) were converted to ticagrelor at a mean of 9.9 h after fibrinolysis with comparable GRACE Risk Scores (median; 158 vs 157, p0.352). The primary composite occurred in 3.5% of ticagrelor and 7.0% of clopidogrel treated patients (p0.014). Following adjustment, ticagrelor was associated with a 54% lower composite outcome (adjusted HR 0.46, 95% confidence interval 0.26–0.84). Major bleeding 6.3% vs 6.1% (NS) and ICH 0.0% vs 0.2% (NS) were similar. Conclusions In a prospective STEMI cohort, switching to ticagrelor compared with sustaining clopidogrel following fibrinolysis pharmacoinvasive reperfusion reduced recurrent ischemic events at 1‐year with no differences in major bleeding or ICH. Aligned with randomized data, these findings provide support to switch pharmaco‐invasively treated STEMI patients.
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Affiliation(s)
- Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jay S Shavadia
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Raymond Leung
- Cardiology, CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Rizzo F, Mezzapesa DM, Chiumarulo L, Parisi M, Loizzo ND, Savarese M, Petruzzellis M. Successful Intravenous Thrombolysis and Endovascular Treatment for Acute Ischemic Stroke in a Patient Pretreated with Ticagrelor: A Case Report and Literature Review. Clin Drug Investig 2021; 41:653-7. [PMID: 34109566 DOI: 10.1007/s40261-021-01047-0] [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] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
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Landzberg DR, English S, Frankel M, Navalkele D. Stroke Thrombolysis in Patients Taking Ticagrelor -Two Successful Cases and a Review of the Literature. J Stroke Cerebrovasc Dis 2020; 30:105520. [PMID: 33310594 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105520] [Citation(s) in RCA: 3] [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] [Received: 11/03/2020] [Revised: 11/22/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ticagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. METHODS We identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. RESULTS Of the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. CONCLUSION Despite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.
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Affiliation(s)
- David R Landzberg
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA
| | - Stephen English
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA
| | - Michael Frankel
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA
| | - Digvijaya Navalkele
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA.
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Berwanger O, Lopes RD, Moia DD, Fonseca FA, Jiang L, Goodman SG, Nicholls SJ, Parkhomenko A, Averkov O, Tajer C, Malaga G, Saraiva JF, Guimaraes HP, de Barros e Silva PG, Damiani LP, Santos RH, Paisani DM, Miranda TA, Valeis N, Piegas LS, Granger CB, White HD, Nicolau JC. Ticagrelor Versus Clopidogrel in Patients With STEMI Treated With Fibrinolysis. J Am Coll Cardiol 2019; 73:2819-2828. [DOI: 10.1016/j.jacc.2019.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/25/2022]
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Berwanger O, Abdelhamid M, Alexander T, Alzubaidi A, Averkov O, Aylward P, Contreras Zúñiga E, Halvorsen S, Iglesias R, A Sk Abdul Kader M, Zubaid M, AlHabib KF. Use of ticagrelor alongside fibrinolytic therapy in patients with ST-segment elevation myocardial infarction: Practical perspectives based on data from the TREAT study. Clin Cardiol 2018; 41:1322-1327. [PMID: 30098028 DOI: 10.1002/clc.23043] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 01/03/2023] Open
Abstract
Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-segment elevation myocardial infarction (STEMI). In patients with STEMI who cannot undergo timely primary PCI, pharmacoinvasive treatment is recommended, comprising immediate fibrinolytic therapy with subsequent coronary angiography and rescue PCI if needed. Improving clinical outcomes following fibrinolysis remains of great importance for the many patients globally for whom rapid treatment with primary PCI is not possible. For patients with acute coronary syndrome who underwent primary PCI, the PLATO trial demonstrated superior efficacy of ticagrelor relative to clopidogrel. Results in the predefined subgroup of patients with STEMI were consistent with the overall PLATO trial. Patients who received fibrinolytic therapy in the 24 hours before randomization were excluded from PLATO, and there is thus a lack of data on the safety of using ticagrelor in conjunction with fibrinolytic therapy in the first 24 hours after STEMI. The TREAT study addresses this knowledge gap; patients with STEMI who had symptom onset within the previous 24 hours and had received fibrinolytic therapy (of whom 89.4% had also received clopidogrel) were randomized to treatment with ticagrelor or clopidogrel (median time between fibrinolysis and randomization: 11.5 hours). At 30 days, ticagrelor was found to be non-inferior to clopidogrel for the primary safety outcome of Thrombolysis in Myocardial Infarction (TIMI)-defined first major bleeding. Considering together the results of the PLATO and TREAT studies, initiating or switching to treatment with ticagrelor within the first 24 hours after STEMI in patients receiving fibrinolysis is reasonable.
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Affiliation(s)
| | | | | | | | - Oleg Averkov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Philip Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | | | | | | | | | | | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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