Relationship between platelet aggregation and stroke risk after percutaneous coronary intervention: a PENDULUM analysis

[Structural and functional features of the main arteries of the brain and tumor necrosis factor-alpha in people with chronic non-infectious diseases]

OBJECTIVE

To investigate the structural and functional characteristics of the carotid and vertebral arteries and their relationship with tumor necrosis factor-alpha (TNF-α) levels in patients with chronic non-infectious diseases (CNIDs), considering sex differences.

Material and Methods. A retrospective analysis of clinical and laboratory data of 760 patients with chronic non-communicable diseases (average age 52.0±14.3 years), was performed. All patients underwent a general clinical examination, measurement of serum TNF-α concentration, and ultrasound examination of the carotid and vertebral arteries. Patients were divided into subgroups of men (n=382) and women (n=378) of comparable age.

RESULTS

Women with CNIDs had lower average levels of hemoglobin and red blood cells but higher levels of platelets, total cholesterol, and creatinine compared to men. Serum TNF-α levels did not significantly differ between men and women. The intima-media thickness (IMT) of the common carotid artery (CCA) and vertebral arteries (VA) was significantly higher in men with CNIDs compared to women. For both sexes, CCA IMT positively correlated with age, systolic and diastolic blood pressure, and C-reactive protein (CRP) concentration, and negatively correlated with glomerular filtration rate (GFR). The IMT of the internal carotid artery in both men and women was closely associated with serum TNF-α levels. In men, VA diameter correlated with age, triglyceride levels, and TNF-α, and negatively with GFR. In women, VA diameter was positively correlated age, systolic blood pressure, CRP, and fibrinogen levels, and negatively correlated with GFR.

CONCLUSION

Structural changes in the arteries supplying the brain are more pronounced in men with CNCIDs. Serum TNF-α levels should be considered in the secondary prevention of cerebrovascular complications in patients with CNIDs.

Drug-herb Synergistic Interactions between Clopidogrel and Natural Medicine

INTRODUCTION

Natural medicine (NM) has been used since ancient times for therapeutic purposes worldwide. Presently, the combination of clopidogrel and NM with a reasonable synergistic effect has gained increasing acceptance in clinical therapeutics.

METHODS

Here, we have performed a comprehensive retrieval of literature published in both English and Chinese databases until August 1, 2022, studying the synergistic interactions of clopidogrel and NM through pharmacokinetic/pharmacodynamic (PK-PD) analyses. We retrieved 7, 3, and 5 studies on PK analysis and 3, 3, and 8 studies on PD analysis for the interaction of clopidogrel with single herbal medicines, bioactive compounds, and herbal prescriptions, respectively. Most studies on NM have been found to mainly focus on preclinical observations, and there have been fewer clinical PK analyses.

RESULTS

A potential drug-herb interaction has been observed to occur when clopidogrel and NM were metabolized by an enzyme network comprising P-gp, CES1, and CYP450. In contrast, most PD studies have focused on clinical observations, and few preclinical findings have been reported. Some cases have suggested that the combination of the two types of drugs would alter the antiplatelet efficacy and adverse effects. Studies on PK, however, have shown significant or slightly varying results for the drug prototype and its metabolites.

CONCLUSION

In the combination therapies, the interaction between clopidogrel and NM was found to alter antiplatelet aggregation pathways and P2Y12 receptor function.

Time-dependent changes in P2Y12 reaction unit values for predicting the different types of cardiovascular events in patients with ischemic heart disease

Several studies have investigated the association between P2Y12 reaction unit (PRU) value and major adverse cardiovascular events (MACEs) in patients with ischemic heart disease, but there is no well-established consensus on the utility of PRU value. Furthermore, the optimal PRU cut-off value varied with studies. One reason may be that the endpoints and observation periods differed, depending on the study. This study aimed to investigate the optimal cut-off and predictive ability of the PRU value for predicting cardiovascular events, while considering different endpoints and observation periods. We surveyed a total of 338 patients receiving P2Y12 inhibitors and measured PRU during cardiac catheterization. Using time-dependent receiver operating characteristic analysis, we evaluated the cut-off and area under curve (AUC) of the PRU value for two MACEs (MACE ①: composite of death, myocardial infarction, stent thrombosis, and cerebral infarction; MACE ②: composite of MACE ① and target vessel revascularization) at 6, 12, 24 and 36 months after cardiac catheterization. MACE ① occurred in 18 cases and MACE ② in 32 cases. The PRU cut-off values at 6, 12, 24, and 36 months were 257, 238, 217, and 216, respectively, for MACE ① and 250, 238, 209, and 204, respectively, for MACE ②. The AUCs at 6, 12, 24, and 36 months were 0.753, 0.832, 0.718, and 0.717, respectively, for MACE ① and 0.724, 0.722, 0.664, and 0.682, respectively, for MACE ②. The optimal cut-off and predictive ability of PRU values for cardiovascular events varied depending on different endpoints and duration of the observation periods. A relatively high PRU value is effective for short-term event suppression, but a low value is required for long-term event suppression.

Comparison of Prasugrel and Clopidogrel in Thrombotic Stroke Patients with Risk Factors for Ischemic Stroke Recurrence: An Integrated Analysis of PRASTRO-I, PRASTRO-II, and PRASTRO-III

INTRODUCTION

Patients with stroke are at a high risk of recurrence, and although they receive antiplatelet therapies such as clopidogrel for secondary prevention of non-cardioembolic stroke, the recurrence rate remains high. Three phase 3 trials (PRASTRO-I/II/III) were conducted to determine the efficacy of prasugrel in preventing recurrent stroke. Here, we performed an integrated analysis of these studies to confirm the generalizability of the PRASTRO-III findings and to supplement the small sample size of the study.

METHODS

Patients from PRASTRO-I, PRASTRO-II, and PRASTRO-III with ischemic stroke (large-artery atherosclerosis or small-artery occlusion) and at least one of the following were included: hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease, or ischemic stroke history. The primary efficacy endpoint was the composite incidence of ischemic stroke, myocardial infarction (MI), and death from other vascular causes in the intention-to-treat population. Bleeding events (life-threatening bleeding, major bleeding, and clinically relevant bleeding) were evaluated as the primary safety endpoint. Cumulative incidences and 95% confidence intervals (CIs) were calculated for the study outcomes using the Kaplan-Meier method. Hazard ratios (HRs) and 95% CIs were calculated using the Cox regression model.

RESULTS

The data of 2,184, 274, and 230 patients from PRASTRO-I, PRASTRO-II, and PRASTRO-III, respectively, were analyzed (N = 2,688; prasugrel, N = 1,337; clopidogrel, N = 1,351). Stroke at enrollment was classified as large-artery atherosclerosis in 49.3% of patients and small-artery occlusion in 50.7% of patients. The primary efficacy endpoint composite incidence (prasugrel vs. clopidogrel) was 3.4% versus 4.3% (HR: 0.771, 95% CI: 0.522-1.138). The incidence of each component of the primary efficacy endpoint for prasugrel versus clopidogrel was 3.1% (n = 41) versus 4.1% (n = 55) for ischemic stroke, 0.3% (n = 4) versus 0.2% (n = 3) for MI, and no events of death from other vascular causes. For the primary safety endpoint, bleeding events were reported in 6.0% of patients in the prasugrel group versus 5.5% of patients in the clopidogrel group (HR: 1.074, 95% CI: 0.783-1.473).

CONCLUSIONS

This integrated analysis supports the findings of PRASTRO-III. Prasugrel is a promising treatment that results in a numerical reduction in the composite incidence of ischemic stroke, MI, and death from other vascular causes in patients with ischemic stroke who are at a high risk of stroke recurrence. No major safety issues were observed for prasugrel.