Dual Antiplatelet Therapy with 3rd Generation P2Y12 Inhibitors in STEMI Patients: Impact of Body Mass Index on Loading Dose-Response

Strategies to optimize initial P2Y12 inhibitor therapy in STEMI patients

INTRODUCTION

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care for patients who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI). Though this regimen reduces rates of ischemic events in patients with STEMI, the optimal strategy for P2Y12 administration in STEMI patients is still evolving.

PURPOSE

The purpose of this review is to summarize current evidence on optimal use of ticagrelor and prasugrel in the acute phase of STEMI.

SUMMARY

Due to high platelet activity in the acute setting of STEMI and PCI, adequate and rapid platelet inhibition is important. Strategies of increased ticagrelor/prasugrel loading dose or earlier administration in STEMI have not been successful in closing this platelet inhibition gap. Potential strategies for improving ticagrelor/prasugrel use early in STEMI include bridging with intravenous antiplatelet agents or crushed or chewed administration.

CONCLUSION

Oral ticagrelor/prasugrel given before or immediately after STEMI PCI is usually sufficient to prevent thrombotic complications. When faster platelet inhibition is desired, or oral administration is compromised by inability to swallow tablets, crushing/chewing ticagrelor/prasugrel tablets is an alternative to intravenous P2Y12 inhibitor therapy.

Safety and Efficacy of Combined Coronary and Peripheral Percutaneous Revascularization: A Proof-of-Concept Study

Background. Lower extremity peripheral artery disease (LEPAD) frequently coexists with coronary artery disease (CAD) in patients with multisite vascular disease (MVD). While percutaneous revascularization is well-established for both LEPAD and CAD, limited evidence exists for patients eligible for both procedures. Specifically, the feasibility of concomitant LEPAD and CAD percutaneous revascularization remains unknown. Objectives. To compare the efficacy and safety of concomitant coronary and lower extremity elective percutaneous revascularization. Methods. Between 2012 and 2021, we included 135 patients in an observational, retrospective single-center registry. The population was stratified into two groups: 45 patients (concomitant group) underwent simultaneous coronary and peripheral percutaneous interventions, and 90 patients (deferred group) underwent two separate procedures within one year. The primary efficacy endpoint was major adverse cardiovascular events (MACE) at one year, while the primary safety endpoint was in-hospital contrast-induced nephropathy (CIN). Results. Study groups were well-balanced in baseline characteristics. In terms of coronary features, the concomitant revascularization group more often underwent single-vessel percutaneous coronary intervention (PCI), while the deferred group had multivessel PCI with diffuse coronary disease. No differences were detected in the number of LEPAD lesions between groups. For the primary efficacy endpoint, the incidence of MACE at one year was 37.8% in the concomitant group vs. 34.4% in the deferred group (HR 1.20, 95% CI 0.64-2.10; p = 0.61). No significant differences were found in CIN occurrence between the concomitant and deferred groups (11.1% vs. 8.9%; OR 1.30; 95% CI 0.36-4.21; p = 0.68). Conclusions. Multisite vascular disease patients eligible for CAD and LEPAD percutaneous revascularization exhibited a high cardiovascular risk profile with diffuse multivessel coronary and lower extremity disease. Our study suggests the efficacy and safety of concomitant coronary and lower extremity percutaneous revascularization based on one-year MACE incidence and in-hospital CIN. However, dedicated studies are warranted to confirm the short- and long-term outcomes of the concomitant revascularization strategy.

Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention : A report from the INVEST-STEMI group

The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2-5 bleedings. The study included 627 patients (median age 63 years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30-0.53). The risk of BARC 2-5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92-1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.

Efficacy and safety of proton pump inhibitors on cardiovascular events and inflammatory factors in patients with upper gastrointestinal bleeding undergoing dual antiplatelet therapy

BACKGROUND

This work evaluated the effects of proton pump inhibitors (PPIs) on cardiovascular events (CVEs) and inflammatory factors in patients with upper gastrointestinal bleeding (UGIB) undergoing dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Clinical data from these patients were analysis, intending to provide relevant theoretical evidence for clinical practice.

MATERIALS AND METHODS

Data of 166 patients who underwent percutaneous coronary intervention and developed UGIB while on DAPT at The First People' Hospital of Linping District from April 2021 to April 2023 were retrospectively analyzed. The patients were rolled into two groups: those who received PPI treatment and those who did not, namely, PPI and non-PPI group, respectively. Furthermore, occurrence of CVEs and the levels of inflammatory factors of patients in all groups were statistically analyzed.

RESULTS

In patients with UGIB, melena is a common presentation. The incidence of CVE in the PPI group showed no statistically significant difference compared to the control group, and there was no significant variance observed in the distribution of CVE incidence among different PPIs. However, levels of C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-α) were significantly lower in the PPI group compared to the non-PPI group (P < 0.05).

CONCLUSION

Melena was the most frequent clinical manifestation in UGIB patients. The use of PPIs did not increase the risk of CVEs, and different PPI drugs did not affect the occurrence of CVEs. Furthermore, PPIs lowered CRP and TNF-α levels in serum of these patients.

Effects of Proton Pump Inhibitors on Cardiovascular Events and Inflammatory Factors in Patients With Upper Gastrointestinal Bleeding Undergoing Dual Antiplatelet Therapy

INTRODUCTION

Dual antiplatelet therapy (DAPT), vital post-percutaneous coronary intervention (PCI) to prevent cardiovascular events (CVEs) via aspirin and P2Y12 receptor antagonists, faces controversy when combined with proton pump inhibitors (PPIs) due to potential impacts on bleeding risk and antiplatelet efficacy, prompting the need for further research to determine optimal co-administration practices. This work evaluated the effects of PPIs on CVEs and inflammatory factors in patients with upper gastrointestinal bleeding (UGIB) undergoing DAPT after PCI.

MATERIALS AND METHODS

The data of 166 patients who underwent PCI and developed UGIB while on DAPT from April 2021 to April 2023 were retrospectively analyzed. The patients were rolled into two groups: those who received PPI treatment and those who did not, namely, the PPI and non-PPI group, respectively. Clinical data from these patients was analyzed, intending to provide relevant theoretical evidence for clinical practice. Furthermore, the occurrence of CVEs and the levels of inflammatory factors of patients in all groups were statistically analyzed.

RESULTS

Melena was the most common clinical symptom observed in all UGIB patients. The incidence of CVEs in the PPI group was not greatly different from that in the non-PPI group (P>0.05). The distribution of CVEs occurrence among different PPI drugs also exhibited no obvious difference (P>0.05). The PPI group exhibited greatly lower C-reactive protein (CRP) and tumor necrosis factor α (TNF-α) based on the non-PPI group (P<0.05).

CONCLUSION

Melena was the most frequent clinical manifestation in UGIB patients. The use of PPIs did not increase the risk of CVEs, and different PPI drugs did not affect the occurrence of CVEs. Furthermore, PPIs lowered CRP and TNF-α levels in serum of these patients.

Soluble PCSK9 Inhibition: Indications, Clinical Impact, New Molecular Insights and Practical Approach-Where Do We Stand?

Current research on cardiovascular prevention predominantly focuses on risk-stratification and management of patients with coronary artery disease (CAD) to optimize their prognosis. Several basic, translational and clinical research efforts aim to determine the etiological mechanisms underlying CAD pathogenesis and to identify lifestyle-dependent metabolic risk factors or genetic and epigenetic parameters responsible for CAD occurrence and/or progression. A log-linear association between the absolute exposure of LDL cholesterol (LDL-C) and the risk of atherosclerotic cardio-vascular disease (ASCVD) was well documented over the year. LDL-C was identified as the principal enemy to fight against, and soluble proprotein convertase subtilisin kexin type 9 (PCSK9) was attributed the role of a powerful regulator of blood LDL-C levels. The two currently available antibodies (alirocumab and evolocumab) against PCSK9 are fully human engineered IgG that bind to soluble PCSK9 and avoid its interaction with the LDLR. As documented by modern and dedicated "game-changer" trials, antibodies against soluble PCSK9 reduce LDL-C levels by at least 60 percent when used alone and up to 85 percent when used in combination with high-intensity statins and/or other hypolipidemic therapies, including ezetimibe. Their clinical indications are well established, but new areas of use are advocated. Several clues suggest that regulation of PCSK9 represents a cornerstone of cardiovascular prevention, partly because of some pleiotropic effects attributed to these newly developed drugs. New mechanisms of PCSK9 regulation are being explored, and further efforts need to be put in place to reach patients with these new therapies. The aim of this manuscript is to perform a narrative review of the literature on soluble PCSK9 inhibitor drugs, with a focus on their indications and clinical impact.

Predictors of Readmission after the First Acute Coronary Syndrome and the Risk of Recurrent Cardiovascular Events-Seven Years of Patient Follow-Up

Recurrent hospitalization after acute coronary syndromes (ACS) is common. Identifying risk factors associated with subsequent cardiovascular events and hospitalization is essential for the management of these patients. Our research consisted in observing the outcomes of subjects after they suffered an acute coronary event and identifying the factors that can predict rehospitalization in the first 12 months and the recurrence of another acute coronary episode. Data from 362 patients admitted with ACS during 2013 were studied. Recurrent hospitalizations were retrospectively reviewed from medical charts and electronic hospital archives over a period of seven years. The mean age of the studied population was 64.57 ± 11.79 years, 64.36% of them being males. The diagnosis of ACS without ST elevation was registered in 53.87% of the patients at index hospitalization. More than half had recurrent hospitalization in the first year after the first ACS episode. Patients with lower ejection fraction (39.20 ± 6.85 vs. 42.24 ± 6.26, p < 0.001), acute pulmonary edema during the first hospitalization (6.47% vs. 1.24%, p = 0.022), coexistent valvular heart disease (69.15% vs. 55.90%, p = 0.017), and three-vessel disease (18.90% vs. 7.45%, p = 0.002) were more frequently readmitted in the following twelve months after their first acute coronary event, while those with complete revascularization were less frequently admitted (24.87% vs. 34.78%, p = 0.005). In multiple regression, complete revascularization during the index event (HR = 0.58, 95% CI 0.35-0.95, p = 0.03) and a higher LVEF (left ventricular ejection fraction) (HR = 0.95, 95% CI 0.92-0.988, p = 0.009) remained independent predictors of fewer early readmissions. Complete revascularization of the coronary lesions at the time of the first event and a preserved LVEF were found to be the predictors of reduced hospitalizations in the first year after an acute coronary event.

Secondary Cardiovascular Prevention after Acute Coronary Syndrome: Emerging Risk Factors and Novel Therapeutic Targets

The control of cardiovascular risk factors, the promotion of a healthy lifestyle, and antithrombotic therapy are the cornerstones of secondary prevention after acute coronary syndrome (ACS). However, many patients have recurrent ischemic events despite the optimal control of traditional modifiable risk factors and the use of tailored pharmacological therapy, including new-generation antiplatelet and lipid-lowering agents. This evidence emphasizes the importance of identifying novel risk factors and targets to optimize secondary preventive strategies. Lipoprotein(a) (Lp(a)) has emerged as an independent predictor of adverse events after ACS. New molecules such as anti-PCSK9 monoclonal antibodies, small interfering RNAs, and antisense oligonucleotides can reduce plasma Lp(a) levels and are associated with a long-term outcome benefit after the index event. The inflammatory stimulus and the inflammasome, pivotal elements in the development and progression of atherosclerosis, have been widely investigated in patients with coronary artery disease. More recently, randomized clinical trials including post-ACS patients treated with colchicine and monoclonal antibodies targeting cytokines yielded promising results in the reduction in major cardiovascular events after an ACS. Gut dysbiosis has also raised great interest for its potential pathophysiological role in cardiovascular disease. This evidence, albeit preliminary and needing confirmation by larger population-based studies, suggests the possibility of targeting the gut microbiome in particularly high-risk populations. The risk of recurrent ischemic events after ACS is related to the complex interaction between intrinsic predisposing factors and environmental triggers. The identification of novel risk factors and targets is fundamental to customizing patient clinical management with a precision medicine perspective.

Drug-drug interactions between antithrombotics and direct-acting antivirals in hepatitis C virus (HCV) patients: A brief, updated report

Hepatitis C virus (HCV) is one of the leading causes of chronic liver disease affecting over 71 million people worldwide. An increased incidence of atherothrombotic events [e.g. coronary artery disease (CAD), atrial fibrillation (AF)] has been observed in HCV seropositive patients. On the other hand, an increased bleeding risk is another clinical issue, particularly in subjects with liver cirrhosis, gastroesophageal varices, portal hypertension, thrombocytopenia and alcohol consumption. The introduction and progressively greater use of direct-acting antivirals (DAAs) (instead of protease and polymerase inhibitors) during the last decade has enabled a sustained virological response to be achieved in a significant percentage of patients. However, due to the high cardiovascular risk profile in HCV-infected patients, the concomitant use of antithrombotic therapies is often required, bearing in mind the possible contraindications. For example, despite better pharmacokinetic and pharmacodynamic properties compared with vitamin K-antagonists, plasma level fluctuations of direct oral anticoagulants (DOACs) due to pathological conditions (e.g. chronic kidney diseases or hepatic cirrhosis) or drug-drug interactions (DDIs) may be of great importance as regards their safety profile and overall clinical benefit. We aimed to examine and briefly summarize the significant DDIs observed between antithrombotic and HCV antiviral drugs.

P2Y12-inhibitor monotherapy after coronary stenting: are all P2Y12-inhibitors equal?

INTRODUCTION

P2Y₁₂-inhibitor monotherapy following 1-3 months of dual antiplatelet therapy (DAPT) reduces (major) bleeding without an apparent increase in ischemic events and has therefore emerged as an alternative to 6-12 months of DAPT following percutaneous coronary intervention (PCI). However, there are important differences between the available P2Y₁₂-inhibitors (clopidogrel, prasugrel, and ticagrelor) as agents of choice for P2Y₁₂-inhibitor monotherapy.

AREAS COVERED

This review critically appraises the evidence for P2Y₁₂-inhibitor monotherapy after PCI using either clopidogrel, prasugrel, or ticagrelor. Furthermore, we discuss ongoing trials and future directions for research.

EXPERT OPINION

P2Y₁₂-inhibitor monotherapy following 1-3 months of DAPT is an alternative to 6-12 months of DAPT following PCI. Ticagrelor may be considered the current preferred option due to its reliable effect on platelet reactivity and its predominant use in clinical trials. Prasugrel could serve as a useful substitute for those not tolerating ticagrelor, but more research into prasugrel monotherapy is warranted. Alternatively, clopidogrel can be used, although there are concerns of high platelet reactivity, especially when genotyping and/or platelet function testing are not used. Future research will need to address the minimal duration of DAPT before switching to P2Y₁₂-inhibitor monotherapy and what the optimal antithrombotic therapy beyond 12 months is.