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Kubota M, Kawakita M, Yoshida S, Kimura H, Sumiyoshi T, Yamasaki T, Okumura K, Yoshimura K, Matsui Y, Sugiyama K, Okuno H, Segawa T, Shimizu Y, Ito N, Onishi H, Ishitoya S, Soda T, Yoshida T, Uemura Y, Iwamura H, Okubo K, Suzuki R, Fukuzawa S, Akao T, Kurahashi R, Shimatani K, Sekine Y, Negoro H, Akamatsu S, Kamoto T, Ogawa O, Kawakami K, Kobayashi T, Goto T. Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy. Sci Rep 2024; 14:5847. [PMID: 38462660 PMCID: PMC10925592 DOI: 10.1038/s41598-024-56570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/08/2024] [Indexed: 03/12/2024] Open
Abstract
This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.
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Affiliation(s)
- Masashi Kubota
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hiroko Kimura
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takayuki Sumiyoshi
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toshinari Yamasaki
- Department of Urology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | | | - Koji Yoshimura
- Department of Urology, Shizuoka General Hospital, Shizuoka, Japan
| | - Yoshiyuki Matsui
- Department of Urology, National Cancer Center Hospital, Tokyo, Japan
| | - Kyohei Sugiyama
- Department of Urology, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroshi Okuno
- Department of Urology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Yosuke Shimizu
- Department of Urology, Kobe City Nishi-Kobe Medical Center, Kobe, Hyogo, Japan
| | - Noriyuki Ito
- Department of Urology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hiroyuki Onishi
- Department of Urology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Satoshi Ishitoya
- Department of Urology, Japanese Red Cross Otsu Hospital, Otsu, Shiga, Japan
| | - Takeshi Soda
- Department of Urology, Kitano Hospital, Osaka, Japan
| | - Toru Yoshida
- Department of Urology, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Yuichi Uemura
- Department of Urology, Toyooka Hospital, Toyooka, Hyogo, Japan
| | - Hiroshi Iwamura
- Department of Urology, Himeji Medical Center, Himeji, Hyogo, Japan
| | | | - Ryosuke Suzuki
- Department of Urology, Numazu City Hospital, Shizuoka, Japan
| | - Shigeki Fukuzawa
- Department of Urology, Shimada General Medical Center, Shizuoka, Japan
| | - Toshiya Akao
- Department of Urology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Ryoma Kurahashi
- Department of Urology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kimihiro Shimatani
- Department of Urology, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Yuya Sekine
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiromitsu Negoro
- Department of Urology, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | | | - Osamu Ogawa
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Urology, Japanese Red Cross Otsu Hospital, Otsu, Shiga, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Takashi Kobayashi
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takayuki Goto
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Kataoka H, Suzuki S, Suzuki Y, Sato R, Sano M, Mogi S, Sakamoto A, Suwa K, Naruse Y, Ohtani H, Saotome M, Shimizu M, Odagiri K, Maekawa Y. Association of Malnutrition and High Bleeding Risk with Long-Term Prognosis in Patients with Acute Coronary Syndrome following Percutaneous Coronary Intervention. MEDICINES (BASEL, SWITZERLAND) 2023; 10:62. [PMID: 38132889 PMCID: PMC10744455 DOI: 10.3390/medicines10120062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/13/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Malnutrition in cardiovascular disease is associated with poor prognosis, especially in patients with heart failure and acute coronary syndrome (ACS). High bleeding risk is also linked to coronary artery disease prognosis, including ACS. However, whether the extent of malnutrition and high bleeding risk have a cumulative impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention remains unclear. METHODS We analyzed 275 patients with ACS treated with percutaneous coronary intervention. The Controlling Nutritional Status score and Japanese version of the Academic Research Consortium for High Bleeding Risk criteria (J-HBR) were retrospectively evaluated. The primary and secondary outcomes were adjusted using the inverse probability treatment weighting method. RESULTS The prevalence of moderate or severe malnutrition in this cohort was 16%. Kaplan-Meier analysis showed a significantly higher incidence of major adverse cardiovascular and cerebrovascular events in patients who were moderately or severely malnourished than in those who were not. Notably, the incidence of these major events was similar between severely malnourished patients with J-HBR and those without. CONCLUSION Moderate or severe malnutrition has a significant impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention.
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Affiliation(s)
- Hiromitsu Kataoka
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Sayumi Suzuki
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Yuichi Suzuki
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Ryota Sato
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Makoto Sano
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Satoshi Mogi
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Atsushi Sakamoto
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Kenichiro Suwa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Yoshihisa Naruse
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Hayato Ohtani
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Masao Saotome
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
| | - Mikihiro Shimizu
- Center for Clinical Research, Hamamatsu University Hospital, Hamamatsu 431-3192, Japan; (M.S.); (K.O.)
| | - Keiichi Odagiri
- Center for Clinical Research, Hamamatsu University Hospital, Hamamatsu 431-3192, Japan; (M.S.); (K.O.)
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan; (H.K.); (S.S.); (Y.S.); (R.S.); (M.S.); (S.M.); (A.S.); (K.S.); (Y.N.); (H.O.); (M.S.)
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Ueapornpanith P, Buranakiti B, Chotayaporn T, Phrommintikul A, Yoodee V. Safety outcomes of ticagrelor among patients with STE-ACS post streptokinase therapy-a retrospective observational study. PLoS One 2023; 18:e0289721. [PMID: 37540686 PMCID: PMC10403104 DOI: 10.1371/journal.pone.0289721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/23/2023] [Indexed: 08/06/2023] Open
Abstract
From the restriction of access to primary percutaneous coronary intervention, about 46% of patients with ST-elevation acute coronary syndrome (STE-ACS) received fibrinolytic therapy as a reperfusion strategy; streptokinase is frequently used in Thailand. Despite the guidelines recommending potent P2Y12 inhibitors among these patients, the data are limited, especially among patients with STE-ACS post streptokinase therapy. The study was proposed to describe factors for P2Y12 inhibitors selection and evaluate outcomes of pharmacoinvasively treated STE-ACS receiving ticagrelor compared with clopidogrel in Thailand. We performed a retrospective observational study of patients with STE-ACS post streptokinase therapy followed by percutaneous coronary intervention (PCI) with coronary stent placement and receiving ticagrelor or clopidogrel as P2Y12 inhibitor treatment from January 2017 to June 2021. The primary outcomes described factors for P2Y12 inhibitor selection and evaluated safety outcomes with inverse probability weight (IPW) adjustment. The secondary outcome was a composite of all-cause death, myocardial infarction and stroke. The median time from streptokinase therapy to initiating ticagrelor in the switch group was 25.7 (IQR, 1.9-4.4) hours. The factors related to switching from clopidogrel to ticagrelor included young age, history of coronary artery disease (CAD), dose of streptokinase and use of intravascular imaging. Any bleeding events occurred among 83 patients (41.71%) in the switch group and 83 patients (41.09%) in the no switch group (adjusted HR 1.04, 95% CI 0.75-1.44; p = 0.826). The composite of efficacy outcomes occurred in 6 patients in the switch group (3.02%) and 12 patients (5.94%) in the no switch group (adjusted HR 0.57, 95% CI 0.21-1.57; p = 0.279). Conclusion: In real practice, ticagrelor switching among patients with STE-ACS post streptokinase therapy did not differ regarding safety outcomes and composite of efficacy outcomes compared with clopidogrel.
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Affiliation(s)
| | | | | | - Arintaya Phrommintikul
- Faculty of Medicine, Department of Internal Medicine, Division of Cardiology, Chiang Mai University, Chiang Mai, Thailand
| | - Voratima Yoodee
- Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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Zhang Y, Chu C, Zhong Z, Luo YB, Ning FF, Guo N. Prolonged dual antiplatelet therapy for Chinese ACS patients undergoing emergency PCI with drug-eluting stents: Benefits and risks. Front Cardiovasc Med 2023; 10:1080673. [PMID: 36873408 PMCID: PMC9976624 DOI: 10.3389/fcvm.2023.1080673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/16/2023] [Indexed: 02/17/2023] Open
Abstract
Background In patients with acute coronary syndrome (ACS), prolonged dual antiplatelet therapy (DAPT) may reduce ischemic events and increase the risks of bleeding events differently in different ethnic groups. However, whether prolonged DAPT in Chinese patients with ACS following emergency percutaneous coronary intervention (PCI) with drug-eluting stents (DES) will be beneficial or dangerous remains unclear. This study aimed to examine the potential benefits and risks of prolonged DAPT in Chinese patients with ACS who have undergone emergency PCI with DES. Methods This study included 2,249 patients with ACS who underwent emergency PCI. If DAPT was continued for 12 or 12-24 months, it was classified as the standard (n = 1,011) or prolonged (n = 1,238) DAPT group, respectively. The incidence of the following endpoint events was determined and compared between the two groups: composite bleeding event (BARC 1 or 2 types of bleeding and BARC 3 or 5 types of bleeding) and major adverse cardiovascular and cerebrovascular events (MACCEs) [ischemia-driven revascularization, non-fatal ischemia stroke, non-fatal myocardial infarction (MI), cardiac death, and all-cause death]. Results After a median period of 47 months of follow-up [47 (40, 54)], the rate of composite bleeding events was 13.2% (n = 163) in the prolonged DAPT group and 7.9% (n = 80) in the standard DAPT group [odds ratio (OR) 1.765, 95% confidence interval (CI) 1.332-2.338, p < 0.001]. The rate of MACCEs was 11.1% (n = 138) in the prolonged DAPT group and 13.2% (n = 133) in the standard DAPT group (OR 0.828, 95% CI 0.642-1.068, p = 0.146). The DAPT duration was further shown to be insignificantly correlated with MACCEs as per the multivariable Cox regression model (HR, 0.813; 95% CI, 0.638-1.036; p = 0.094). No statistically significant difference was observed between the two groups. However, the DAPT duration was a separate predictor of composite bleeding events according to the multivariable Cox regression model (HR 1.704, 95% CI 1.302-2.232, p < 0.001). Compared with the standard DAPT group, the prolonged DAPT group had substantially more BARC 3 or 5 types of bleeding events (3.0 vs. 0.9% in those with standard DAPT, OR 3.430, 95% CI 1.648-7.141, p < 0.001) and BARC 1 or 2 types of bleeding events (10.2 vs. 7.0% in those with standard DAPT, OR 1.500, 95% CI 1.107-2.032, p = 0.008). Conclusion The prolonged DAPT group had a considerably greater incidence of composite bleeding events than the standard DAPT group. No statistically significant difference was observed in the incidence of MACCEs between the two groups.
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Affiliation(s)
- Yong Zhang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chao Chu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zhong Zhong
- Department of Cardiovascular Medicine, Weinan Central Hospital, Weinan, Shaanxi, China
| | - Yong-Bai Luo
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Fei-Fei Ning
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ning Guo
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Xu JJ, Jia SD, Jiang L, Song Y, Zhu P, Yuan DS, Yao Y, Zhao XY, Li JX, Yang YJ, Qiao SB, Xu B, Gao RL, Yuan JQ. Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome: five-year results from a large cohort study. World J Emerg Med 2023; 14:25-30. [PMID: 36713350 PMCID: PMC9842462 DOI: 10.5847/wjem.j.1920-8642.2023.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To investigate the most appropriate dual antiplatelet therapy (DAPT) duration for patients with acute coronary syndrome (ACS) after drug-eluting stent (DES) implantation in the largest cardiovascular center of China. METHODS We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013. Patients were divided into four groups based on DAPT duration: standard DAPT group (11-13 months, n=1,568) and prolonged DAPT groups (13-18 months [n=308], 18-24 months [n=2,125], and >24 months [n=1,186]). Baseline characteristics and 5-year clinical outcomes were recorded. RESULTS Baseline characteristics were similar across the four groups. Among the four groups, those with prolonged DAPT (18-24 months) had the lowest incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) (14.1% vs. 11.7% vs. 9.6% vs. 24.2%, P<0.001), all-cause death (4.8% vs. 3.9% vs. 2.1% vs. 2.6%, P<0.001), cardiac death (3.1% vs. 2.6% vs. 1.4% vs. 1.9%, P=0.004), and myocardial infarction (MI) (3.8% vs. 4.2% vs. 2.5% vs. 5.8%, P<0.001). The incidence of bleeding was not different among the four groups (9.9% vs. 9.4% vs. 11.0% vs. 9.4%, P=0.449). Cox multivariable analysis showed that prolonged DAPT (18-24 months) was an independent protective factor for MACCEs (hazard ratio [HR] 0.802, 95% confidence interval [CI] 0.729-0.882, P<0.001), all-cause death (HR 0.660, 95% CI 0.547-0.795, P<0.001), cardiac death (HR 0.663, 95% CI 0.526-0.835, P<0.001), MI (HR 0.796, 95% CI 0.662-0.957, P=0.015), and target vessel revascularization (HR 0.867, 95% CI 0.755-0.996, P=0.044). Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs. CONCLUSION For patients with ACS after DES, appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.
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Affiliation(s)
- Jing-jing Xu
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Si-da Jia
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lin Jiang
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Ying Song
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Pei Zhu
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - De-shan Yuan
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Yao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xue-yan Zhao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jian-xin Li
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yue-jin Yang
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shu-bin Qiao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Run-lin Gao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China,Run-lin Gao,
| | - Jin-qing Yuan
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China,Corresponding Author: Jin-qing Yuan, ;
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Naganawa H, Ito A, Saiki S, Nishi D, Takamatsu S, Ito Y, Suzuki T. The Efficacy of Drug-Coated Balloon for Acute Coronary Syndrome. Cardiol Res Pract 2023; 2023:4594818. [PMID: 37122873 PMCID: PMC10139813 DOI: 10.1155/2023/4594818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 01/01/2023] [Accepted: 04/15/2023] [Indexed: 05/02/2023] Open
Abstract
Background Percutaneous coronary intervention using a drug-eluting stent (DES) is a common therapeutic option for acute coronary syndrome (ACS). However, stent-associated complications, such as bleeding associated with dual antiplatelet therapy, in-stent restenosis, stent thrombosis, and neoatherosclerosis, remain. Drug-coated balloons (DCBs) are expected to reduce stent-associated complications. This study aimed to assess the efficacy of DCB therapy and compare it with that of DES therapy in patients with ACS. Materials and Methods In this single-center, retrospective, observational study, we examined all patients with ACS treated with DCB or DES between July 2014 and November 2020. Patients with left main trunk lesions were excluded. The primary outcome was a composite of major adverse cardiovascular events (MACE: cardiac death, myocardial infarction, and target lesion revascularization) at one year. Results Three hundred and seventy-two patients were treated with DES, and 83 patients were treated with DCB. MACE occurred in 10 (12.0%) patients in the DCB group and in 50 (13.4%) patients in the DES group (P=0.73). Conclusions DCB is a valuable and effective therapy for patients with ACS. Moreover, DCB may become an alternative therapy for DES in patients with ACS.
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Affiliation(s)
- Hirokazu Naganawa
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Akira Ito
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Shinrou Saiki
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Daisuke Nishi
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Shinichi Takamatsu
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Yoshihisa Ito
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
| | - Takeshi Suzuki
- Department of Cardiology, Toyokawa City Hospital, Toyokawa, Aichi, Japan
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Triple Antiplatelet Therapy with Cilostazol and Favorable Early Clinical Outcomes after Acute Myocardial Infarction Compared to Dual Antiplatelet Therapy with Standard or Potent P2Y12 Inhibitors. J Clin Med 2022; 11:jcm11226856. [PMID: 36431333 PMCID: PMC9693255 DOI: 10.3390/jcm11226856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
Current guidelines for the management of acute myocardial infarction (AMI) recommend potent P2Y12 inhibitors rather than clopidogrel to prevent ischemic events. However, their ischemic benefits are offset by an increased major bleeding risk. We compared the efficacy and safety of triple antiplatelet therapy with cilostazol in the first month after AMI. This study investigated 16,643 AMI patients who received percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in nationwide, real-world, multicenter registries in Korea. Patients were divided into DAPT (aspirin and clopidogrel, n = 11,285), Triple (aspirin, clopidogrel and cilostazol, n = 2547), and Potent (aspirin and ticagrelor/prasugrel, n = 2811) groups. The primary outcomes were net adverse clinical events (NACE), a composite of death from any cause, myocardial infarction (MI), stroke, and TIMI major bleeding one month after AMI. After adjusting for covariates, there were no statistically significant differences in the risk of death from any cause, MI, or stroke between the three groups. However, the risk of TIMI major bleeding was significantly greater in the Potent group than in the DAPT and Triple groups (p < 0.001). Accordingly, NACE was significantly higher in the DAPT (HR 1.265; 95% CI 1.006−1.591, p = 0.044) and Potent groups (HR 1.515; 95% CI 1.142−2.011, p = 0.004) than in the Triple group. Triple antiplatelet therapy with cilostazol was associated with an improved net clinical outcome in the first month after AMI without increasing the risk of bleeding compared to potent or standard P2Y12 inhibitor-based DAPT.
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Heindl B, Clarkson S, Parcha V, Dillon C, Narayan R, Usifo E, Hillegass W, Irvin MR, Arora P, Zhai G, Beasley M, Limdi N. Risk of Postdischarge Bleeding From Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Among US Black and White Adults. J Am Heart Assoc 2022; 11:e024412. [PMID: 36073636 PMCID: PMC9683679 DOI: 10.1161/jaha.121.024412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
Background Dual antiplatelet therapy after percutaneous coronary intervention reduces myocardial infarctions but increases bleeding. The risk of bleeding may be higher among Black patients for unknown reasons. Bleeding risk scores have not been validated among Black patients. We assessed the difference in bleeding risk between Black and White patients along with the performance of the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti Platelet Therapy, Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients, and Academic Research Consortium for High Bleeding Risk scores among both groups. Methods and Results This was a single-center prospective study of patients who underwent percutaneous coronary intervention (2014-2019) and were followed for 1 year. The outcome was postdischarge Bleeding Academic Research Consortium 2 to 5 bleeding. Incidence rates were reported. Cox proportional hazards models measured the effect of self-reported Black race on bleeding and determined the predictors of bleeding among 19 a priori variables. The 3 risk scores were assessed among Black and White patients separately using the Harrell concordance index. Of 1529 included patients, 342 (22.4%) self-reported as being Black race. Unadjusted bleeding rates were 22.7 per 100 person-years among Black patients versus 16.3 among White patients (hazard ratio, 1.41 [95% CI, 1.00-2.00], P=0.052). Predictors of bleeding were age, glomerular filtration rate <30 mL/min per 1.73 m2, prior bleeding, ticagrelor or prasugrel use, and anticoagulant use. Among Black and White patients, respectively, the C-indexes were the following: 0.644 versus 0.600 for Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti Platelet Therapy (P<0.001 for both), 0.620 versus 0.612 for Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients (P=0.003 and P<0.001, respectively), and 0.600 versus 0.598 for Academic Research Consortium for High Bleeding Risk (P=0.006 and P<0.001, respectively). Conclusions The risk of dual antiplatelet therapy-associated postdischarge Bleeding Academic Research Consortium 2 to 5 bleeding was not significantly different between self-reported Black and White patients. Bleeding risk scores performed similarly among both groups.
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Affiliation(s)
- Brittain Heindl
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Stephen Clarkson
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Vibhu Parcha
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Chrisly Dillon
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
| | - Renuka Narayan
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
| | - Ebikere Usifo
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
| | - William Hillegass
- Department of Data Science, School of Public HealthUniversity of Mississippi Medical CenterJacksonMS
| | | | - Pankaj Arora
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Guihua Zhai
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAL
| | - Mark Beasley
- School of Public HealthUniversity of Alabama at BirminghamBirminghamAL
| | - Nita Limdi
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
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9
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Hori M, Zhu J, Liang Y, Bhatt DL, Bosch J, Connolly SJ, Fox KAA, Maggioni A, Yusuf S, Eikelboom JW. Rivaroxaban and aspirin vs. aspirin alone in Asian compared with non-Asian patients with chronic coronary artery disease or peripheral arterial disease: the COMPASS trial. Eur Heart J 2022; 43:3542-3552. [PMID: 35751528 DOI: 10.1093/eurheartj/ehac309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/15/2022] [Accepted: 05/26/2022] [Indexed: 01/02/2023] Open
Abstract
AIMS It is unknown whether Asian and non-Asian patients with atherosclerotic vascular disease derive similar benefits from long-term antithrombotic therapy. METHODS AND RESULTS In patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD) enrolled in The Cardiovascular Outcomes for People Using Anticoagulation Strategies trial, the effects of rivaroxaban 2.5 mg b.i.d. plus aspirin 100 mg o.d. were compared with those of aspirin 100 mg o.d. in Asian vs. non-Asian patients (race was self-identified). Asians (n = 4269) vs. non-Asians (n = 23 126) had similar rates of major adverse cardiovascular events (MACEs) (4.85% vs. 4.83%, P = 0.30) and modified International Society on Thrombosis and Haemostasis (ISTH) major bleeding (2.72% vs. 2.58%, P = 0.22), but higher rates of intracranial haemorrhage (ICH) (0.63% vs. 0.29%, P = 0.01) and minor bleeding (13.61% vs. 6.49%, P < 0.001). In Asians vs. non-Asians, the combination of rivaroxaban and aspirin compared with aspirin alone produced consistent reductions in MACE [Asians: hazard ratio (HR): 0.64, 95% confidence interval (CI): 0.45-0.90; non-Asians: HR: 0.78, 95% CI: 0.67-0.90; P(heterogeneity) = 0.29], increases in modified ISTH major bleeding (Asians: HR 2.24, 95% CI: 1.40-3.58; non-Asians: HR: 1.60, 95% CI: 1.30-1.97; P = 0.20), and net clinical outcome (Asians: HR: 0.77, 95% CI: 0.56-1.05; non-Asians: HR: 0.81, 95% CI: 0.70-0.93, P = 0.78), but borderline higher rates of ICH (Asians: HR: 3.50, 95% CI: 0.98-12.56; non-Asians: HR: 0.81, 95% CI: 0.43, 1.53; P = 0.04). CONCLUSION Asian compared with non-Asian patients with chronic CAD and/or PAD have higher rates of ICH and minor bleeding. The combination of rivaroxaban and aspirin vs. aspirin alone produces similar effects for MACE, modified ISTH major bleeding, and net clinical outcome but may be associated with higher rates of ICH in Asian patients.
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Affiliation(s)
| | - Jun Zhu
- FuWai Hospital, Beijing, China
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | | | - Stuart J Connolly
- McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada.,Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Salim Yusuf
- McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada.,Hamilton Health Sciences Hamilton, Ontario, Canada
| | - John W Eikelboom
- McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada.,Hamilton Health Sciences Hamilton, Ontario, Canada
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10
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Nakagawa Y, Kadota K, Nakao K, Shite J, Yokoi H, Kozuma K, Tanabe K, Akasaka T, Shinke T, Ueno T, Hirayama A, Uemura S, Iijima R, Harada A, Kuroda T, Takita A, Murakami Y, Saito S, Nakamura M. Early P2Y 12 Inhibitor Single Antiplatelet Therapy for High-Bleeding Risk Patients After Stenting - PENDULUM Mono 24-Month Analysis. Circ J 2022; 86:1352-1361. [PMID: 35584932 DOI: 10.1253/circj.cj-21-1004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In PENDULUM mono, Japanese patients with high bleeding risk (HBR) received short-term dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) with prasugrel after percutaneous coronary intervention (PCI). One-year data from PENDULUM mono showed better outcomes with prasugrel monotherapy after short-term DAPT compared with matched patients in the PENDULUM registry with longer DAPT durations according to guidelines at that time. This study presents 2-year results.Methods and Results: We compared 24-month data from PENDULUM mono (n=1,107; de-escalation strategy group) and the PENDULUM registry (n=2,273; conventional strategy group); both were multicenter, non-interventional, prospective registry studies, using the inverse probability of treatment weighting (IPTW) method. In the PENDULUM mono group, the cumulative incidence of clinically relevant bleeding (CRB) at 24 months post-PCI (primary endpoint) was 6.8%, and that of major adverse cardiac and cerebrovascular events (MACCE) was 8.9%. After IPTW adjustment, the cumulative incidence of CRB was 5.8% and 7.2% in PENDULUM mono and the PENDULUM registry, respectively (hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.57-1.04; P=0.086), and that of MACCE was 8.0% and 9.5%, respectively (HR 0.77; 95% CI 0.59-1.01; P=0.061). CONCLUSIONS Japanese PCI patients with HBR prescribed prasugrel SAPT after short-term DAPT had a lower ischemic event risk than those prescribed long-term DAPT, and this was particularly relevant for ischemic events after 1 year.
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Affiliation(s)
- Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | | | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Junya Shite
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Takafumi Ueno
- Department of Cardiovascular Medicine, Fukuoka Kinen Hospital
| | | | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Raisuke Iijima
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | - Takeshi Kuroda
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | | | - Shigeru Saito
- Division of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
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11
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Gao F, Rahman F. DOACs and Atherosclerotic Cardiovascular Disease Management: Can We Find the Right Balance Between Efficacy and Harm. Curr Atheroscler Rep 2022; 24:457-469. [PMID: 35386093 DOI: 10.1007/s11883-022-01022-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The balance between efficacy and harm remains a challenge in the adoption of non-vitamin K antagonist direct oral anticoagulants (DOACs) for secondary atherosclerotic disease prevention. We provide a comprehensive review of the evidence for and against the addition of DOACs to the current management of atherosclerotic cardiovascular disease, including stable coronary artery disease (CAD), acute coronary syndrome (ACS), peripheral artery disease (PAD), and percutaneous coronary interventions (PCI). RECENT FINDINGS The DOAC class exerts pleiotropic effects on atherosclerotic progression through coagulation and inflammatory pathways. In ACS, low-dose DOAC provides no added efficacy in the setting of dual antiplatelet therapy; however, full-dose DOAC increases bleeding. Efficacy-safety profile favor use of low-dose rivaroxaban in select stable CAD or PAD patients. Atrial fibrillation patients undergoing PCI resort to dual therapy with DOAC due to prohibitory bleeding with triple anti-thrombotic therapy. Evidence favors DOAC use in CAD and PAD; however, careful individual considerations must be undertaken.
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Affiliation(s)
- Feng Gao
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Faisal Rahman
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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12
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Ng AKY, Ng PY, Ip A, Lau KK, Siu CW. Risk of ischaemic and haemorrhagic stroke in Chinese undergoing percutaneous coronary intervention treated with potent P2Y12 inhibitor versus clopidogrel. Stroke Vasc Neurol 2022; 7:310-318. [PMID: 35264399 PMCID: PMC9453842 DOI: 10.1136/svn-2021-001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/02/2022] [Indexed: 11/21/2022] Open
Abstract
Background Stroke after acute coronary syndrome (ACS) can be devastating. It is uncertain whether the risks of ischaemic stroke or intracranial haemorrhage (ICH) are associated with different choices of P2Y12 inhibitors (potent P2Y12 inhibitors such as ticagrelor and prasugrel vs clopidogrel). Even though East Asians are known to have different thrombotic and haemorrhagic profiles from Caucasians, data on Chinese patients are sparse. Method This was a retrospective cohort study conducting in Chinese patients with ACS who underwent first-ever percutaneous coronary intervention from 14 hospitals in Hong Kong between 2010 and 2017. The primary efficacy endpoint was ischaemic stroke. The secondary efficacy endpoint was a composite outcome of thrombotic events including all-cause mortality, non-fatal myocardial infarction and ischaemic stroke. The primary safety endpoint was ICH. The secondary safety endpoint was a composite of major bleeding events. Results After adjustment of baseline characteristics by 1:1 propensity score matching, a total of 6220 patients (3110 on each group) were analysed. Compared with clopidogrel, potent P2Y12 inhibitors were associated with a lower risk of ischaemic stroke (HR 0.57; 95% CI 0.37 to 0.87; p=0.008) and a lower risk of thrombotic events (HR 0.77; 95% CI 0.66 to 0.90; p=0.001). Potent P2Y12 inhibitor was associated with similar risk of ICH (HR 0.65; 95% CI 0.34 to 1.25, p=0.20) and major bleeding (HR 0.83; 95% CI 0.68 to 1.01, p=0.069). Conclusions Potent P2Y12 inhibitors were associated with a lower adjusted risk of ischaemic stroke and thrombotic events, compared with clopidogrel. The risks of ICH and major bleeding were similar.
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Affiliation(s)
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - April Ip
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
| | - Kui Kai Lau
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong.,The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong
| | - Chung-Wah Siu
- Department of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
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13
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Kwon O, Park DW. Antithrombotic Therapy After Acute Coronary Syndromes or Percutaneous Coronary Interventions in East Asian Populations. JACC. ASIA 2022; 2:1-18. [PMID: 36340250 PMCID: PMC9627845 DOI: 10.1016/j.jacasi.2021.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/13/2021] [Accepted: 12/03/2021] [Indexed: 05/01/2023]
Abstract
Because guidelines and recommendations in response to multiple randomized clinical trials (RCTs) of new therapies undergo rapid changes, antithrombotic therapies for patients after acute coronary syndrome, or percutaneous coronary intervention, are becoming more complex in daily clinical practice. The proportion of Asian populations enrolled in landmark RCTs is substantially low, which limits the direct application of trial findings into clinical practice in Asian countries. Moreover, compared with Caucasian patients, East Asian patients are considered to have a different ischemia/bleeding propensity in response to antithrombotic therapy, known as the "East Asian paradox" (ie, more bleeding events but fewer thromboembolic events). Coincident with consecutive RCTs in Western populations to optimize antithrombotic strategies, several such studies have now been conducted in East Asian cohorts. Herein, we provide a comprehensive summary of the key RCTs in this regard and propose future directions and perspectives for optimal antithrombotic therapies in East Asian patients.
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Key Words
- ACS, acute coronary syndrome
- BARC, Bleeding Academic Research Consortium
- CAD, coronary artery disease
- CHIP, complex higher-risk and indicated procedure/patients
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent
- DOAC, direct oral anticoagulant
- HBR, high bleeding risk
- MI, myocardial infarction
- OAC, oral anticoagulation
- PCI, percutaneous coronary intervention
- PRU, P2Y12 reaction unit
- RCT, randomized controlled trial
- acute coronary syndrome
- antiplatelets
- antithrombotic therapy
- percutaneous coronary intervention
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Affiliation(s)
- Osung Kwon
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St Mary's Hospital, Seoul, South Korea
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Address for correspondence: Dr Duk-Woo Park, Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.
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14
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Lee SY, Cho YK, Kim SW, Hong YJ, Koo BK, Bae JW, Lee SH, Yang TH, Park HS, Choi SW, Lim DS, Kim SJ, Jeong YH, Lee HJ, Lee KY, Shin ES, Kim U, Kim MH, Nam CW, Hur SH, Kim DI. Clinical Results of Drug-Coated Balloon Treatment in a Large-Scale Multicenter Korean Registry Study. Korean Circ J 2022; 52:444-454. [PMID: 35491479 PMCID: PMC9160640 DOI: 10.4070/kcj.2021.0261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 01/27/2022] [Accepted: 02/23/2022] [Indexed: 11/24/2022] Open
Abstract
Current percutaneous coronary intervention has significant limitations related to the implanted current metallic stent. The “leave nothing behind” strategy of drug-coated balloon (DCB) treatment has showed potential performance to overcome current treatment. However, studies in this issue are still limited by moderate numbers of patients. Therefore, we performed Stent Failure Research DCB registry study to evaluate the efficacy and safety of DCB treatment for in-stent restenosis or de novo lesions. The registry finally included 2,509 patients treated with DCB and revealed the favorable clinical outcome of DCB treatment. Background and Objectives The aim of this study was to demonstrate the efficacy and safety of treatment with drug-coated balloon (DCB) in a large real-world population. Methods Patients treated with DCBs were included in a multicenter observational registry that enrolled patients from 18 hospitals in Korea between January 2009 and December 2017. The primary outcome was target lesion failure (TLF) defined as a composite of cardiovascular death, target vessel myocardial infarction, and clinically indicated target lesion revascularization at 12 months. Results The study included 2,509 patients with 2,666 DCB-treated coronary artery lesions (1,688 [63.3%] with in-stent restenosis [ISR] lesions vs. 978 [36.7%] with de novo lesions). The mean age with standard deviation was 65.7±11.3 years; 65.7% of the patients were men. At 12 months, the primary outcome, TLF, occurred in 179 (6.7%), 151 (8.9%), 28 (2.9%) patients among the total, ISR, and de novo lesion populations, respectively. A history of hypertension, diabetes, acute coronary syndrome, previous coronary artery bypass graft, reduced left ventricular ejection fraction, B2C lesion and ISR lesion were independent predictors of 12 months TLF in the overall study population. Conclusions This large multicenter DCB registry study revealed the favorable clinical outcome of DCB treatment in real-world practice in patient with ISR lesion as well as small de novo coronary lesion.
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Affiliation(s)
- Sang Yeub Lee
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Yun-Kyeong Cho
- Department of Cardiology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Sang-Wook Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young-Joon Hong
- Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seung-Hwan Lee
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Tae Hyun Yang
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hun Sik Park
- Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Si Wan Choi
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Do-Sun Lim
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Soo-Joong Kim
- Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Korea
| | - Young Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | | | | | - Eun-Seok Shin
- Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Ung Kim
- Department of Internal Medicine, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Moo Hyun Kim
- Department of Internal Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Chang-Wook Nam
- Department of Cardiology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Seung-Ho Hur
- Department of Cardiology, Keimyung University Dongsan Hospital, Daegu, Korea
| | - Doo-Il Kim
- Department of Cardiology, Inje University Haeundae Baek Hospital, Inje University College of Medicine, Busan, Korea
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15
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Ma Y, Zhong PY, Shang YS, Bai N, Niu Y, Wang ZL. Efficacy and Safety of Short-Term Dual Antiplatelet Therapy in East Asians: A Systematic Review and a Meta-Analysis of Randomized Clinical Trials. J Cardiovasc Pharmacol 2021; 79:264-272. [PMID: 34813573 PMCID: PMC8893122 DOI: 10.1097/fjc.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/06/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The optimal duration of dual antiplatelet therapy (DAPT) for patients implanted with new-generation drug-eluting stents in East Asians is currently still controversial. The purpose of this meta-analysis was to investigate the efficacy and safety of short-term DAPT in patients with those. In this study, randomized controlled trials from PubMed, EMBASE, and Cochrane Library were searched to compare the efficacy and safety of short-term DAPT (6 months or less) with long-term DAPT (12 months or more) in patients implanted with new-generation drug-eluting stents in East Asian from inception to September 2020. The primary efficacy outcome was all-cause death, the primary safety outcome was major bleeding, and the secondary outcomes included cardiovascular death, myocardial infarction, definite or possible stent thrombosis, and stroke. A total of 6 randomized controlled trials with 15,688 patients met inclusion criteria; there were no significant differences in the incidence of all-cause death [risk ratio (RR), 1.03; 0.76-1.39; P = 0.856)], cardiovascular death (RR, 0.83; 0.55-1.24; P = 0.361), myocardial infarction (RR, 0.97; 0.72-1.31; P = 0.853), definite or possible stent thrombosis (RR, 1.52; 0.83-2.78; P = 0.170), and stroke (RR, 0.90; 0.61-1.31; P = 0.574) between short-term and long-term DAPTs. However, there was a significant difference in the risk of major bleeding (RR, 0.64; 0.49-0.85; P = 0.002) between the 2 groups. Compared with long-term DAPT, the short-term DAPT can reduce the risk of major bleeding without increasing the risk of death or ischemia for East Asians (Registered by PROSPERO, CRD42020213266).
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Affiliation(s)
- Ying Ma
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Peng-Yu Zhong
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Yao-Sheng Shang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Nan Bai
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Ying Niu
- The First Clinical Medical College of Lanzhou University, Lanzhou, China; and
| | - Zhi-Lu Wang
- Department of Cardiology, the First Hospital of Lanzhou University, Lanzhou, China
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16
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Wang W, Shao C, Xu B, Wang J, Yang M, Chen J, Zhang K, Wang S, Li P, Tang YD. CYP2C19 genotype has prognostic value in specific populations following coronary stenting. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1066. [PMID: 34422978 PMCID: PMC8339845 DOI: 10.21037/atm-20-7724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/28/2021] [Indexed: 11/06/2022]
Abstract
Background The prognostic value of the CYP2C19 genotype in post-percutaneous coronary intervention (PCI) patients remains controversial. The recently-published, limited-sample PHARMCLO trial indicates a personalized pharmacogenomic approach may reduce adverse events. This study aimed to determine the prognostic value of CYP2C19 genotypes. Methods The original cohort consisted of 10,724 PCI patients in 2013. 756 patients with genotyped CYP2C19 were included in our analysis. The CYP2C19 genotype prognostic value was tested based on different clinical factors. The primary endpoint was major adverse cardio- and cerebro-vascular event (MACCE). Results MACCE 2-years post-PCI occurred in 19 patients (17.4%) in poor metabolizers (PM, CYP2C19 *2/*2, *2/*3, *3/*3), 43 patients (12.2%) in intermediate metabolizers (IM, CYP2C19 *1/*2 or *1/*3) and 27 patients (9.2%) in extensive metabolizers (EM, CYP2C19 *1/*1). PM was an independent MACCE predictor compared with EM (HR: 1.960, 95% CI: 1.139–3.372), but the difference between IM and PM was not significant (HR: 1.314, 95% CI: 0.843–2.048). Major bleeding (BARC grade ≥3) was not significantly different between the three groups (2.5% vs. 2.1% vs. 0.8%, P=0.133). Subgroup analysis showed that the CYP2C19 genotype prognostic value was present in the following subgroups: male, age >60 years, body mass index (BMI) >24 kg/m2, SYNTAX score >15, current smokers, and patients without chronic kidney disease. Conclusions Utilizing CYP2C19 genotype to guide post-PCI antiplatelet therapy might be appropriate in patients with the following characteristics: male, age >60 years, BMI >24 kg/m2, SYNTAX score >15, current smokers, and non-chronic kidney disease (CKD) patients.
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Affiliation(s)
- Wenyao Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunli Shao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Catheterization Laboratory, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjia Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kuo Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyuan Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Li
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Da Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, China
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17
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Ndrepepa G, Holdenrieder S, Cassese S, Kastrati A. Creatine kinase and bleeding in patients with acute coronary syndromes. Eur J Clin Invest 2021; 51:e13514. [PMID: 33570770 DOI: 10.1111/eci.13514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/01/2021] [Accepted: 02/08/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The association between elevated creatine kinase (CK) and bleeding in patients with acute coronary syndrome (ACS) remains incompletely investigated. We undertook this study to assess whether there is an association between elevated CK activity and the risk for bleeding in contemporary patients with ACS. MATERIALS AND METHODS This post hoc analysis of a randomized trial included 3368 patients with ACS undergoing percutaneous coronary intervention. CK was measured serially in all patients until hospital discharge. The main outcome was 30-day incidence of major bleeding (type 3 to 5 bleeding according to the Bleeding Academic Research Consortium criteria). RESULTS Patients were categorized in groups according to the peak CK tertiles: 1st tertile (CK ≤259 U/L; n = 1127 patients), 2nd tertile (CK ≥260 to 990 U/L; n = 1119 patients), and 3rd tertile (CK ≥ 991 U/L; n = 1122 patients). Peak CK activity was higher in patients with bleeding than those without bleeding (771 [316-1845] U/L vs. 496 [190-1357] U/L; P <.001). Bleeding occurred in 26 patients (2.3%) with peak CK within 1st tertile, 39 patients (3.5%) with peak CK within 2nd tertile, and 54 patients (4.8%) with peak CK within 3rd tertile (univariable hazard ratio [HR]=1.39, 95% confidence interval [CI] 1.08 to 1.81, P =.012, per tertile increment in CK values). After adjustment, peak CK activity remained significantly associated with the 30-day bleeding (HR = 1.67 [1.16-2.41]; P =.006 per unit increment in logarithmic CK values). The C statistic of the multivariable model with CK activity was 0.807 [0.770-0.842]. CONCLUSIONS In patients with ACS, peak CK activity was independently associated with increased 30-day incidence of bleeding.
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Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Stefan Holdenrieder
- Institut für Laboratoriumsmedizin, Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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18
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Kim HK, Tantry US, Park HW, Shin ES, Geisler T, Gorog DA, Gurbel PA, Jeong YH. Ethnic Difference of Thrombogenicity in Patients with Cardiovascular Disease: a Pandora Box to Explain Prognostic Differences. Korean Circ J 2021; 51:202-221. [PMID: 33655720 PMCID: PMC7925962 DOI: 10.4070/kcj.2020.0537] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 01/07/2023] Open
Abstract
Arterial and venous atherothrombotic events are finely regulated processes involving a complex interplay between vulnerable blood, vulnerable vessel, and blood stasis. Vulnerable blood ('thrombogenicity') comprises complex interactions between cellular components and plasma factors (inflammatory, procoagulant, anticoagulant, and fibrinolytic factors). The extent of thrombogenicity may determine the progression of atheroma and the clinical manifestation of atherothrombotic events, with the highest thrombogenicity in African Americans and lowest in East Asians. Inherent thrombogenicity may influence clinical efficacy and safety of specific antithrombotic treatments in high-risk patients, which may in part explain the observation that East Asian patients have reduced anti-ischemic benefits and elevated bleeding risk with antithrombotic therapy compared to Caucasian patients. In this review, we discuss available evidence regarding the racial differences in thrombogenicity and its impact on clinical outcomes among patients with atherosclerotic cardiovascular disease.
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Affiliation(s)
- Hyun Kuk Kim
- Department of Cardiology, Chosun University Hospital, Gwangju, Korea
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Hyun Woong Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Division of Cardiology, Gyeongsang National University Hospital, Jinju, Korea
| | - Eun Seok Shin
- Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tübingen, Tübingen, Germany
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Young Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of the Health Sciences, Gyeongsang National University, Jinju, Korea.
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19
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Zhang Y, Shi XJ, Peng WX, Han JL, Lin BD, Zhang R, Zhang YN, Yan JL, Wei JJ, Wang YF, Chen SW, Nan N, Fang ZW, Zeng Y, Lin Y. Impact of Implementing CYP2C19 Genotype-Guided Antiplatelet Therapy on P2Y 12 Inhibitor Selection and Clinical Outcomes in Acute Coronary Syndrome Patients After Percutaneous Coronary Intervention: A Real-World Study in China. Front Pharmacol 2021; 11:582929. [PMID: 33551797 PMCID: PMC7854467 DOI: 10.3389/fphar.2020.582929] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/21/2020] [Indexed: 12/04/2022] Open
Abstract
Background: CYP2C19 loss-of-function (LOF) alleles reduce the effectiveness of clopidogrel in patients undergoing percutaneous coronary intervention for acute coronary syndrome. However, the clinical impact of implementing CYP2C19 gene-guided pharmacotherapy is unclear, especially among the Chinese population. The purpose of this study was to evaluate P2Y12 receptor inhibitor selection and clinical outcomes upon implementation of CYP2C19 genotype-guided pharmacotherapy in current clinical practice. Methods: This was a single-center observational cohort study. Adult percutaneous coronary intervention patients who received CYP2C19 genetic testing (*2, *3, *17 alleles) were included. Ticagrelor was recommended for patients with a LOF allele. Factors related to P2Y12 inhibitor selection were determined by logistic regression. The primary endpoint was major cardiac or cerebrovascular adverse events (MACCE) within 12 months. MACCE and clinically significant bleeding events (BARC ≥2) in the LOF-clopidogrel group, non-LOF-clopidogrel group, and non-LOF-ticagrelor group were compared with those in the LOF-ticagrelor group. The inverse probability of treatment weighting (IPTW) was adjusted in a Cox regression analysis to eliminate confounding factors. Results: Among 1,361 patients, 826 (60.7%) had a LOF allele. Patients with a LOF allele were more likely to be prescribed ticagrelor (multivariate-adjusted OR 1.349; 95% CI 1.040 to 1.751; p = 0.024). The MACCE rate was higher in the LOF-clopidogrel group than in the LOF-ticagrelor group (7.8 vs. 4.0%; log-rank p = 0.029; IPTW-adjusted HR 2.138; 95% CI 1.300–3.515). Compared with the LOF-ticagrelor group, the non-LOF-clopidogrel group showed no significant difference in MACCE rate (5.8 vs. 4.0%; log-rank p = 0.272; IPTW-adjusted HR 1.531; 95% CI 0.864–2.714). Among the patients treated with ticagrelor, there was no significant difference in the MACCE rate between the LOF group and non-LOF group (4.3 vs. 4.0%; log-rank p = 0.846; IPTW-adjusted HR 1.184; 95% CI 0.582–2.410). There was no significant difference in the incidence of clinically significant bleeding events among the four groups. Conclusion: This study confirms that efficiently returned CYP2C19 genotype results did partially guide cardiologists to prescribe ticagrelor for patients with a LOF allele, and that clopidogrel had a higher risk of MACCE than ticagrelor in these patients, which provides support for the implementation of CYP2C19 gene-guided antiplatelet therapy in clinical practice.
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Affiliation(s)
- Yi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiu-Jin Shi
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen-Xing Peng
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jia-Lun Han
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bai-Di Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ru Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yun-Nan Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jia-Lin Yan
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Juan-Juan Wei
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Fan Wang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Su-Wei Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Nan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhen-Wei Fang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yong Zeng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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20
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Kang DO, An H, Park GU, Yum Y, Park EJ, Park Y, Jang WY, Kim W, Choi JY, Roh SY, Na JO, Kim JW, Kim EJ, Rha SW, Park CG, Seo HS, Choi CU. Cardiovascular and Bleeding Risks Associated With Nonsteroidal Anti-Inflammatory Drugs After Myocardial Infarction. J Am Coll Cardiol 2021; 76:518-529. [PMID: 32731930 DOI: 10.1016/j.jacc.2020.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/02/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Limited data are available regarding the risk for adverse clinical events with concomitant nonsteroidal anti-inflammatory drug (NSAID) treatment after myocardial infarction (MI). OBJECTIVES The aim of this study was to investigate the risk for cardiovascular and bleeding events according to groups of antithrombotic medications and subtypes of NSAIDs in patients with MI. METHODS This was a nationwide cohort study to enroll a study population from the Health Insurance Review and Assessment Service database in Korea between 2009 and 2013. Patients were divided into groups on the basis of the prescribed antithrombotic medications. The primary and secondary outcomes were thromboembolic cardiovascular and clinically relevant bleeding events. The risk for adverse clinical events was assessed by ongoing NSAID treatment and subtypes of NSAIDs. RESULTS In total, 108,232 patients (mean age 64.2 ± 12.8 years, 72.1% men, mean follow-up duration 2.3 ± 1.8 years) with first diagnosed MI were enrolled. Concomitant NSAID treatment significantly increased the risk for cardiovascular events (hazard ratio [HR]: 6.96; 95% confidence interval [CI]: 6.24 to 6.77; p < 0.001) and bleeding events (HR: 4.08; 95% CI: 3.51 to 4.73; p < 0.001) compared with no NSAID treatment. Among NSAID subtypes, the risk for cardiovascular and bleeding events was lowest with the use of celecoxib (HR: 4.65; 95% CI: 3.17 to 6.82; p < 0.001, and 3.44; 95% CI: 2.20 to 5.39; p < 0.001, respectively) and meloxicam (HR: 3.03; 95% CI: 1.68 to 5.47; p < 0.001, and 2.80; 95% CI: 1.40 to 5.60; p < 0.001, respectively). CONCLUSIONS Concomitant NSAID treatment significantly increased the risk for cardiovascular and bleeding events after MI. Although NSAID treatment should be avoided after MI, celecoxib and meloxicam could be considered as alternative options in cases in which NSAID use is unavoidable.
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Affiliation(s)
- Dong Oh Kang
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyonggin An
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | | | - Yunjin Yum
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Eun Jin Park
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yoonjee Park
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Won Young Jang
- Division of Cardiology, Department of Internal Medicine, Catholic University of Korea St. Vincent's Hospital, Suwon, Korea
| | - Woohyeun Kim
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jah Yeon Choi
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seung-Young Roh
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jin Oh Na
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jin Won Kim
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eung Ju Kim
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Chang Gyu Park
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hong Seog Seo
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
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21
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van Uden RCAE, Houtenbos I, Griffioen-Keijzer A, Odekerken DAM, van den Bemt PMLA, Becker ML. Guidelines for mono, double and triple antithrombotic therapy. Postgrad Med J 2021; 97:730-737. [PMID: 33441477 DOI: 10.1136/postgradmedj-2020-138938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/13/2020] [Accepted: 11/23/2020] [Indexed: 12/24/2022]
Abstract
Guidelines for antithrombotic therapy are complex, especially if a patient has several indications that require antithrombotic therapy. In general, no patient should receive lifelong double or triple antithrombotic therapy. In this overview, we outline the most common indications for mono, double and triple antithrombotic therapy; the preferred antithrombotic therapy and the recommended duration of therapy. Both antiplatelet therapy and therapeutic anticoagulation therapy with vitamin K antagonists or direct oral anticoagulants were included. European guidelines were used or, if no European guidelines were available, the Dutch guidelines were used.
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Affiliation(s)
- Renate C A E van Uden
- Hospital Pharmacy, Spaarne Gasthuis, Haarlem, Noord-Holland, Netherlands.,Pharmacy Foundation of Haarlem Hospitals, Haarlem, Noord-Holland, Netherlands
| | - Ilse Houtenbos
- Internal Medicine, Spaarne Gasthuis, Haarlem, Noord-Holland, Netherlands
| | | | | | - Patricia M L A van den Bemt
- Clinical Pharmacy and Pharmacology, Universitair Medisch Centrum Groningen, Groningen, Groningen, Netherlands
| | - Matthijs L Becker
- Hospital Pharmacy, Spaarne Gasthuis, Haarlem, Noord-Holland, Netherlands .,Pharmacy Foundation of Haarlem Hospitals, Haarlem, Noord-Holland, Netherlands
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22
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Nakamura M, Iijima R. Implications and characteristics of high bleeding risk in East Asian patients undergoing percutaneous coronary intervention: Start with what is right rather than what is acceptable. J Cardiol 2020; 78:91-98. [PMID: 33358236 DOI: 10.1016/j.jjcc.2020.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 11/25/2022]
Abstract
Recent advances in percutaneous coronary intervention (PCI) technology and medication have changed the main focus of PCI from preventing ischemic to preventing bleeding events. Bleeding risk assessment is essential for preventing bleeding. Several types of assessment tools have been established, but they are heterogeneous, making interpretation, generalization, and comparison between trials difficult. In 2019, the Academic Research Consortium (ARC) introduced a new consensus document with 20 criteria to define high bleeding risk (HBR). The applicability of the ARCHBR criteria were subsequently investigated, and 4 studies have already demonstrated wide applicability worldwide, including in Japan. Nevertheless, it hase been suggested that bleeding risk is higher in people from East Asian countries than in people from Western countries. Patients with HBR have a 3-fold higher risk of major bleeding, and in Japan approximately 50% of patients undergoing PCI have HBR. In addition, patients with overlapping factors, such as older age, renal disease, and anemia, are at increased risk of bleeding, and each additional factor further increases the risk. In Japanese patients undergoing PCI, in addition to the ARC-HBR criteria, low body weight, heart failure, and peripheral arterial disease are high-risk subsets for bleeding. The addition of these factors to the ARCHBR criteria increases the prevalence of HBR in Japanese patients to 58% and improves the sensitivity of diagnostic evaluations. The additional factors are clinically important because they are often encountered in everyday practice, and Japan's newly updated guideline has adopted them as criteria for HBR. Studies found a temporal trend over the past 20 years of a gradual and consistent increase of bleeding risk. This finding contrasts with improved outcomes in people at risk of ischemic and thrombotic events. Therefore, further research is needed to eliminate the risk of bleeding while maintaining the efficacy of antithrombotic therapy after PCI.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan.
| | - Raisuke Iijima
- Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
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23
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Brewster LM, Fernand J. Creatine kinase is associated with bleeding after myocardial infarction. Open Heart 2020; 7:openhrt-2020-001261. [PMID: 32675301 PMCID: PMC7368484 DOI: 10.1136/openhrt-2020-001261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/20/2020] [Accepted: 05/01/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The ADP-scavenging enzyme creatine kinase (CK) is reported to reduce ADP-dependent platelet activation. Therefore, we studied whether highly elevated CK after ST-elevation myocardial infarction (STEMI) is associated with bleeding. METHODS Data of the Thrombolysis in Myocardial Infarction Study Group phase II trial on the efficacy of angioplasty, following intravenous recombinant tissue-type plasminogen activator (rt-PA), are used to assess whether peak plasma CK (CKmax) is independently associated with adjudicated fatal or non-fatal bleeding (primary) and combined bleeding/all-cause mortality (secondary) in multivariable binomial logistic regression analysis, adjusting for baseline and treatment allocation covariates. RESULTS The included patients (n=3339, 82% men, 88% white, mean age 57 years, SE 0.2) had a history of angina pectoris (55%), hypertension (38%) and/or diabetes mellitus (13%). CKmax ranged from 16 to 55 890 IU/L (mean 2389 IU/L, SE 41), reached within 8 hours in 51% of the patients (93% within 24 hours). Adjudicated fatal/non-fatal bleeding occurred in 30% of the patients (respectively 26% in the low vs 34% in the high CK tertile), and bleeding/all-cause mortality in 35% (29% in the low vs 40% in the high CK tertile). In multivariable regression analysis, the adjusted OR for fatal/non-fatal bleeding (vs not bleeding and survival) was 2.6 (95% CI 1.8 to 3.7)/log CKmax increase, and 3.1 (2.2 to 4.4) for bleeding/all-cause mortality. CONCLUSION Highly elevated plasma CK after myocardial infarction might be an independent predictor of bleeding and haemorrhagic death. This biologically plausible association warrants further prospective study of the potential role of extracellular CK in ADP-dependent platelet activation and bleeding.
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Affiliation(s)
| | - Jim Fernand
- Clinic for Health and Individual Medicine, Utrecht, The Netherlands
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24
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Xu J, Song Y, Gao Z, Jiang P, Liu R, Wang H, Qiao S, Gao R, Yang Y, Xu B, Yuan J. Long-term outcomes of extending dual antiplatelet therapy after drug-eluting stent implantation for acute coronary syndrome: a large single-center study. Platelets 2020; 31:869-876. [PMID: 31741412 DOI: 10.1080/09537104.2019.1693036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
To date, DAPT duration of 1 year is the standard treatment for ACS patients after DES implantation in China. However, less is known about the effect of prolonging DAPT duration of long-term outcome for this kind of patient in the real world of China. We carried out a large sample case in the biggest cardiovascular center in China to observe the effect of prolonging DAPT duration for more than 1 year on long-term outcome in ACS patients after PCI. We enrolled 5187 consecutive patients with ACS who underwent DES implantation from January 2013 to December 2013. We recorded when DAPT was discontinued, and analyzed patients' data comparing different DAPT durations (DAPT = 1 year or >1 year). Two-year clinical outcomes were compared between patients from the two groups. The baseline characteristics were almost the same between the two groups, except the number of stents per patient (DAPT = 1 year vs. >1 year, 1.80 ± 1.02 vs. 1.86 ± 1.05, p = .04). Patients with DAPT = 1 year had a higher incidence of all-cause death (1.8% vs. 0.1%, p < .01), cardiac death (0.8% vs. 0.1%, p < .01), and stent thrombosis (0.7% vs. 0.2%, p < .01) vs. DAPT > 1 year, respectively. Logistic regression analysis indicated that the number of stents per patient was an independent factor for prolonged DAPT (odds ratio: 1.07, 95% confidence interval (CI): 1.01-1.14, p = .03). Cox regression analysis showed that the independent risk predictors of all-cause death were age and cardiac dysfunction, whereas the independent protective predictors were body mass index and DAPT > 1 year. In the subgroup analysis of high bleeding risk, the DAPT > 1-year group still experienced a lower incidence of all-cause death. For patients with ACS undergoing DES implantation, 1 year of DAPT may be not sufficient. Appropriate prolongation of DAPT may relate to the reduction of the incidence of adverse cardiovascular events and it does not increase the bleeding events, even for the patients with high bleeding risk.
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Affiliation(s)
- Jingjing Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Ying Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Zhan Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Ping Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Ru Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Huanhuan Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Shubin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Runlin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Yuejin Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
| | - Jinqing Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College , Beijing, China
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25
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Cho H, Kang J, Kim HS, Park KW. Ethnic Differences in Oral Antithrombotic Therapy. Korean Circ J 2020; 50:645-657. [PMID: 32725974 PMCID: PMC7390713 DOI: 10.4070/kcj.2020.0098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/22/2020] [Indexed: 02/04/2023] Open
Abstract
Oral antithrombotic therapy (antiplatelet therapy and anticoagulation therapy) is a key element of pharmacotherapy in patients with cardiovascular (CV) disease. Several reports of ethnic differences have suggested that there may be difference therapeutic requirements and response to therapy for antithrombotic therapy. In particular for East Asians, there seems to be a lower incidence of ischemic outcomes and a higher incidence of bleeding outcomes compared to Westerners. The purpose of this review is to describe the ethnicity-related differences in antithrombotic therapy for CV disease and to discuss the need to establish a more effective and targeted antithrombotic treatment strategy in East Asians.
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Affiliation(s)
- Haechan Cho
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyo Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
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The optimal duration of dual antiplatelet therapy in East Asian patients undergoing percutaneous coronary intervention with drug-eluting stents: a meta-analysis of randomized trials. Coron Artery Dis 2020; 32:119-130. [PMID: 32639246 DOI: 10.1097/mca.0000000000000921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The optimal duration of dual antiplatelet therapy (DAPT) is still controversial among East Asians. This meta-analysis was designed to evaluate the efficacy and safety of short-term (≤6 months) vs. long-term (≥12 months) DAPT in East Asians undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). METHODS PubMed, Embase, Web of Science and the Cochrane Library were searched for articles published up to 30 March 2020. Then meta-analysis was performed using RevMan 5.3 software. RESULTS Nine studies with a total of 20 177 East Asian patients were included in this meta-analysis. In East Asian patients, short-term DAPT was associated with a lower incidence of major bleeding [odds ratio (OR) = 0.70, 95% confidence interval (CI) (0.49, 0.99), P = 0.04]. In the newer-generation DES subgroup, short-term DAPT was no less effective than long-term DAPT and resulted in a lower incidence of major bleeding [OR = 0.69, 95% CI (0.49, 0.98), P = 0.04]. In the subgroup of patients with acute coronary syndrome, there was no significant difference in the incidence of cardiac death, net adverse clinical and cerebral events (NACCE) and major bleeding between short-term and long-term DAPT. It was worth noting that in the subgroup of patients with diabetes mellitus, short-term DAPT was associated with a higher incidence of myocardial infarction [OR = 2.64, 95% CI (1.19, 5.88), P = 0.02] and NACCE [OR = 1.92, 95% CI (1.07, 3.43), P = 0.03]. CONCLUSION The short-term DAPT (≤6 months) might be a better choice for East Asian patients undergoing PCI with DES, especially the newer-generation DES. However, for high-risk patients such as diabetes, the analysis supported the longer DAPT.
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Numasawa Y, Sawano M, Fukuoka R, Ejiri K, Kuno T, Shoji S, Kohsaka S. Antithrombotic Strategy for Patients with Acute Coronary Syndrome: A Perspective from East Asia. J Clin Med 2020; 9:jcm9061963. [PMID: 32585929 PMCID: PMC7356748 DOI: 10.3390/jcm9061963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga 326-0843, Japan
- Correspondence: ; Tel.: +81-284-21-0121; Fax: +81-284-21-6810
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Ryoma Fukuoka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY 10003, USA;
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
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Nakamura M, Kadota K, Takahashi A, Kanda J, Anzai H, Ishii Y, Shibata Y, Yasaka Y, Takamisawa I, Yamaguchi J, Takeda Y, Harada A, Motohashi T, Iijima R, Uemura S, Murakami Y. Relationship Between Platelet Reactivity and Ischemic and Bleeding Events After Percutaneous Coronary Intervention in East Asian Patients: 1-Year Results of the PENDULUM Registry. J Am Heart Assoc 2020; 9:e015439. [PMID: 32394794 PMCID: PMC7660889 DOI: 10.1161/jaha.119.015439] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The balance between ischemic and bleeding events and their association with platelet reactivity in patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI), which differs among regions, is not fully evaluated for East Asians. We examined ischemic/bleeding events and platelet reactivity in Japanese patients undergoing PCI and determined associations between high/low platelet reactivity and clinical outcomes. Methods and Results PENDULUM (Platelet Reactivity in Patients with Drug Eluting Stent and Balancing Risk of Bleeding and Ischemic Event) is a prospective, multicenter registry of Japanese patients with PCI. Primary end points were incidence of first major adverse cardiac and cerebrovascular events (MACCE) and first major bleeding events at 12 months post-PCI. Platelet reactivity (P2Y12 reaction unit [PRU] value) was measured at 12 to 48 hours post-PCI; patients were grouped as having high PRU (>208), optimal PRU (>85 to ≤208), and low PRU (≤85). MACCE and major bleeding occurred in 4.4% and 2.8% of 6267 patients, respectively. The mean±SD PRU value was 182.1±77.1. MACCE was significantly higher in the high PRU (5.7%; n=2227) versus the optimal PRU group (3.6%; n=3002). The hazard ratio (HR) for high PRU versus optimal PRU level was significantly higher for MACCE (adjusted HR, 1.53; 95% CI, 1.14-2.06 [P=0.004]); stent thrombosis followed the same trend. Incidence of major bleeding did not differ significantly between groups. A high PRU level was significantly associated with MACCE in both patients with and patients without acute coronary syndrome. Conclusions These real-world data suggest an association between high platelet reactivity and cardiovascular events in Japanese patients undergoing PCI. The trend was the same in both patients with and patients without acute coronary syndrome. REGISTRATION URL: https://www.umin.ac.jp/ctr. Unique identifier: UMIN 000020332.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Kazushige Kadota
- Department of Cardiology Kurashiki Central Hospital Kurashiki Japan
| | | | - Junji Kanda
- Department of Cardiology Asahi General Hospital Asahi Japan
| | - Hitoshi Anzai
- Department of Cardiology Ota Memorial Hospital Ota Japan
| | - Yasuhiro Ishii
- Department of Cardiology Cardiovascular Center Ogikubo Hospital Tokyo Japan
| | - Yoshisato Shibata
- Department of Cardiology Miyazaki Medical Association Hospital Miyazaki Japan
| | - Yoshinori Yasaka
- Department of Cardiology Himeji Cardiovascular Center Himeji Japan
| | | | - Junichi Yamaguchi
- Department of Cardiology Tokyo Women's Medical University Tokyo Japan
| | - Yoshihiro Takeda
- Department of Cardiology Rinku General Medical Center Izumisano Japan
| | - Atsushi Harada
- Medical Science Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Tomoko Motohashi
- Medical Affairs Planning Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Raisuke Iijima
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Shiro Uemura
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Yoshitaka Murakami
- Department of Medical Statistics School of Medicine Toho University Tokyo Japan
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One-year clinical outcomes of ticagrelor compared with clopidogrel after percutaneous coronary intervention in patients with acute myocardial infarction: From Korean Health Insurance Review and Assessment Data. J Cardiol 2020; 73:191-197. [PMID: 30770037 DOI: 10.1016/j.jjcc.2018.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Ticagrelor has been widely accepted in clinical practice for treatment of acute myocardial infarction (AMI), however its clinical safety and efficacy have not been revealed sufficiently in Asian populations. METHODS AND RESULTS Among a total 20,270 patients (age <75 years) with AMI undergoing percutaneous coronary intervention who received dual antiplatelet therapy for at least 30 days, clinical outcomes at 1 year were assessed from the database of Health Insurance Review and Assessment Service in Korea between 2013 and 2014. Ticagrelor showed a significant effect on reduction of all-cause death [stabilized inverse probability of treatment weighted (sIPTW)-adjusted odds ratio (aOR) 0.57, 95% confidence interval (CI) 0.42-0.77, p<0.001]. Stroke was also reduced by using ticagrelor (sIPTW-aOR 0.58, 95% CI 0.41-0.82, p=0.002). Bleeding risk was not increased by ticagrelor use. There were nearly 30% of patients who switched from ticagrelor to different P2Y12 inhibitors. Switching P2Y12 inhibitors was associated with clinical adverse events including MI, stroke, and bleeding. CONCLUSIONS Among patients aged younger than 75 years, ticagrelor was associated with lower incidence of all-cause mortality. Stroke risk was also reduced in patients with a prescription for ticagrelor without an increase in bleeding risk.
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Nakamura M, Kimura K, Kimura T, Ishihara M, Otsuka F, Kozuma K, Kosuge M, Shinke T, Nakagawa Y, Natsuaki M, Yasuda S, Akasaka T, Kohsaka S, Haze K, Hirayama A. JCS 2020 Guideline Focused Update on Antithrombotic Therapy in Patients With Coronary Artery Disease. Circ J 2020; 84:831-865. [DOI: 10.1253/circj.cj-19-1109] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Masaharu Ishihara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yoshihisa Nakagawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shiga University of Medical Science
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Kazuo Haze
- Department of Cardiology, Kashiwara Municipal Hospital
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Kim W, Kim JS, Rha SW, Choi BG, Jang WY, Kang DO, Park Y, Choi JY, Roh SY, Na JO, Choi CU, Kim EJ, Park CG, Seo HS, Choi SY, Byun JK, Cha J, Oh DJ, Jeong MH. Cilostazol-based triple versus potent P2Y12 inhibitor-based dual antiplatelet therapy in patients with acute myocardial infarction undergoing percutaneous coronary intervention. Heart Vessels 2020; 35:1181-1192. [PMID: 32270356 DOI: 10.1007/s00380-020-01598-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/27/2020] [Indexed: 11/28/2022]
Abstract
Although potent P2Y12 inhibitor-based dual antiplatelet therapy (DAPT) has replaced clopidogrel-based therapy as the standard treatment in patients with acute myocardial infarction (AMI), there is a concern about the risk of bleeding in East Asian patients. We compared the efficacy and safety of cilostazol-based triple antiplatelet therapy (TAT) with potent P2Y12 inhibitor-based DAPT in Korean patients. A total of 4152 AMI patients who underwent percutaneous coronary intervention (PCI) in the Korea Acute Myocardial Infarction Registry were analyzed retrospectively. Patients were divided into two groups: the TAT group (aspirin + clopidogrel + cilostazol, n = 3161) and the potent DAPT group (aspirin + potent P2Y12 inhibitors [ticagrelor or prasugrel], n = 991). Major clinical outcomes at 30 days and 2 years were compared between the two groups using propensity score matching (PSM) analysis. After PSM (869 pairs), there were no significant differences between the two groups in the incidence of total death, cardiac death, myocardial infarction (MI), target vessel revascularization, stent thrombosis, and stroke at 30 days and 2 years. However, the Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding rates were significantly lower in the TAT group compared with the potent DAPT group at 2 years (6.4% vs. 3.6%, p = 0.006). In Korean AMI patients undergoing PCI, TAT with cilostazol was associated with lower bleeding than the potent P2Y12 inhibitor-based DAPT without increased ischemic risk. These results could provide a rationale for the use of TAT in East Asian AMI patients.
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Affiliation(s)
- Woohyeun Kim
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jin-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-si, Republic of Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea. .,Cardiovascular Intervention Research Institute, Seoul, Republic of Korea.
| | - Byoung Geol Choi
- College of Medicine, Institute of Health Science, Korea University, Seoul, Republic of Korea
| | - Won Young Jang
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Dong Oh Kang
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Yoonjee Park
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jah Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Seung-Young Roh
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jin Oh Na
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Cheol Ung Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Eung Ju Kim
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Chang Gyu Park
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Hong Seog Seo
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Se Yeon Choi
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jae Kyeong Byun
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Jinah Cha
- Cardiovascular Center, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, Republic of Korea
| | - Dong Joo Oh
- Cardiovascular Intervention Research Institute, Seoul, Republic of Korea
| | - Myung Ho Jeong
- Heart Center of Chonnam, National University Hospital, Gwangju, Republic of Korea
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Xi Z, Zhou Y, Zhao Y, Liu X, Liang J, Chai M, Yu Y, Liu W. Ticagrelor Versus Clopidogrel in Patients with Two CYP2C19 Loss-of-Function Alleles Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2020; 34:179-188. [DOI: 10.1007/s10557-020-06956-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Efficacy and Safety of Long-Term and Short-Term Dual Antiplatelet Therapy: A Meta-Analysis of Comparison between Asians and Non-Asians. J Clin Med 2020; 9:jcm9030652. [PMID: 32121235 PMCID: PMC7141296 DOI: 10.3390/jcm9030652] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023] Open
Abstract
While dual antiplatelet therapy (DAPT) is essential after percutaneous coronary intervention (PCI), the optimal duration is affected by various factors. However, the effect of ethnicity on DAPT duration has not been fully evaluated. In this study, we evaluated the different effect of DAPT duration by ethnicity. We searched Pubmed, Embase, Cochrane library, and relevant websites to search for randomized clinical trials (RCT) assessing the clinical impact of long term DAPT (L-DAPT) and short term DAPT (S-DAPT). Studies were divided by ethnicity, and we compared the efficacy and safety of DAPT duration in each ethnic group. Thirteen RCTs including 38,255 patients (five East Asian studies and eight non–East Asian studies) were eligible for analysis. For the primary outcome, L-DAPT showed a significantly lower rate of primary outcome only in non–East Asians (S-DAPT vs. L-DAPT, odds ratio (OR) = 1.16, 95% confidence interval (CI): 1.02–1.32, p = 0.02), while in East Asians, the effect of S-DAPT and L-DAPT were comparable. S-DAPT significantly increased ischemic events only in non–East Asians (S-DAPT vs. L-DAPT, OR = 1.24, 95% CI: 1.09–1.42, p <0.01), while bleeding events were decreased by S-DAPT in both ethnicities. These results demonstrate that the adequate DAPT duration after PCI may be different in East Asians.
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Gong L, Fu C, Bi L, Kuang Y, Guo C, Wei G, Yan Z, Huang J, Yang G. Pharmacokinetics and bioequivalence of low-dose clopidogrel in healthy Chinese volunteers under fasted and fed conditions. Drug Metab Pharmacokinet 2019; 34:300-307. [PMID: 31239099 DOI: 10.1016/j.dmpk.2019.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 05/09/2019] [Accepted: 05/27/2019] [Indexed: 01/01/2023]
Abstract
Clopidogrel is an antiplatelet drug whose performance at a low dose (25 mg) have not been evaluated in Chinese patients, who may be subject to different effects from Caucasians. We carried out this evaluation and compared a generic (Taijia) and a reference drug (Plavix®). We evaluated Taijia and Plavix® in 128 subjects, with 64 in a fasted state and 64 receiving a high-fat diet, and computed Cmax, AUC0-∞, and AUC0-t. Reference-scaled average bioequivalence (RSABE) methods and average bioequivalence (ABE) methods were used, and adverse events were assessed. Average maximum plasma concentrations (Cmax) of clopidogrel were significantly greater after 25 mg dose under fed conditions compared to fasted. Reference-scaled Cmax, AUC0-t, and AUC0-∞ were higher than the 0.294 cutoff during fasted, meeting RSABE criteria. Under fed conditions, SWR for AUC0-t and AUC0-∞ were lower than 0.294, permitting use of ABE. The 90% confidence intervals for AUC0-t and AUC0-∞ indicated bioequivalence. Pharmacokinetic parameters differed between fasted and fed states. The generic product was bioequivalent to the reference drug, and was safe and well tolerated. This suggests that they can be used interchangeably in a clinical setting.
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Affiliation(s)
- Liying Gong
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China; Center of Clinical Drug Evaluation, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China
| | - Chengxiao Fu
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China; Center of Clinical Drug Evaluation, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China
| | - Lucun Bi
- Bioanalytical Chemistry Covance, Shanghai, PR China
| | - Yun Kuang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China; Center of Clinical Drug Evaluation, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China
| | - Chengxian Guo
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China; Center of Clinical Drug Evaluation, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China
| | - Guolan Wei
- Bioanalytical Chemistry Covance, Shanghai, PR China
| | - Zhaofeng Yan
- Bioanalytical Chemistry Covance, Shanghai, PR China
| | - Jie Huang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China; Center of Clinical Drug Evaluation, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China.
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China; Center of Clinical Drug Evaluation, The Third Xiangya Hospital, Central South University, Changsha, Hunan, PR China.
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Yoshida R, Ishii H, Morishima I, Tanaka A, Morita Y, Takagi K, Yoshioka N, Hirayama K, Iwakawa N, Tashiro H, Kojima H, Mitsuda T, Hitora Y, Furusawa K, Tsuboi H, Murohara T. Performance of HAS-BLED, ORBIT, PRECISE-DAPT, and PARIS risk score for predicting long-term bleeding events in patients taking an oral anticoagulant undergoing percutaneous coronary intervention. J Cardiol 2019; 73:479-487. [DOI: 10.1016/j.jjcc.2018.10.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/29/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022]
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Li YH, Chiu YW, Cheng JJ, Hsieh IC, Lo PH, Lei MH, Ueng KC, Chiang FT, Sung SH, Kuo JY, Chen CP, Lai WT, Lee WL, Chen JH. Duration of Clopidogrel-Based Dual Antiplatelet Therapy and Clinical Outcomes in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention - A Real-World Observation in Taiwan From 2012 to 2015. Circ J 2019; 83:1317-1323. [PMID: 31061379 DOI: 10.1253/circj.cj-18-1283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little information is available in Asia about the real-world practice of dual antiplatelet therapy (DAPT) duration for acute coronary syndrome (ACS) and its influence on clinical outcomes.Methods and Results:The Taiwan ACS STENT Registry was a prospective, multicenter study to observe ACS patients using clopidogrel-based DAPT after percutaneous coronary intervention (PCI). The primary outcome was a composite of cardiovascular death, myocardial infarction, and stroke. Overall, 2,221 ACS patients (62 years, 83% men) were included. DAPT duration was ≤9 months in 935 (42.1%). The incidence of primary outcome was higher in patients receiving DAPT ≤9 months compared with those receiving DAPT >9 months at 1 year (3.5% vs. 1.6%, P=0.0026). The incidence of stent thrombosis (overall 0.5%) was similar between groups. Multivariable analysis showed that DAPT >9 months was associated with a significantly lower risk of primary outcome (odds ratio 0.725, 95% confidence interval 0.545-0.965). CONCLUSIONS Our data showed that short duration of DAPT (≤9 months) was common (42.1%) in Taiwan for ACS patients undergoing PCI. DAPT ≤9 months increased the risk of the primary outcome.
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Affiliation(s)
- Yi-Heng Li
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yu-Wei Chiu
- Department of Computer Science and Engineering, Yuan Ze University, Far Eastern Memorial Hospital
| | | | - I-Chang Hsieh
- Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Ping-Han Lo
- China Medical University Hospital and College of Medicine
| | | | | | - Fu-Tien Chiang
- National Taiwan University Hospital and Fu-Jen Catholic University Hospital
| | - Shih-Hsien Sung
- Taipei Veterans General Hospital and National Yang Ming University
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Utility of the HAS-BLED score for risk stratification of patients with acute coronary syndrome. Heart Vessels 2019; 34:1621-1630. [PMID: 30969359 DOI: 10.1007/s00380-019-01405-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 04/05/2019] [Indexed: 12/12/2022]
Abstract
HAS-BLED score was developed for bleeding prediction in patients with atrial fibrillation (AF). Recently, it was also used in patients undergoing percutaneous coronary interventions (PCI). This study analyzes the HAS-BLED predictivity for bleedings and mortality in patients with acute coronary syndromes (ACS) without AF, and evaluates the utilization of alternative criteria for renal dysfunction. The study population was composed of 704 patients with ACS. Six-hundred and eleven patients completed the follow-up. The HAS-BLED score was calculated both using the original definition of renal dysfunction, both using three alternative eGFR thresholds (< 30, < 60 and ≤ 90 ml/min/1.73 mq). In-hospital and post-discharge bleedings and mortality were recorded, and calibration and discrimination of the various risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic. In-hospital bleedings were 4.7% and mortality was 2.7%. Post-discharge bleedings were 3.1% and mortality was 4.4%. Regarding bleeding events and in-hospital mortality, the HAS-BLED original risk model demonstrated a moderate-to-good discriminative performance (C-statistics from 0.65 to 0.76). No significant differences were found in predictive accuracy when applying alternative definitions of renal dysfunction based on eGFR, with the exception of post-discharge mortality, for which HAS-BLED model assuming an eGFR value < 60 ml/min/1.73 mq showed a discriminative performance significantly higher in comparison to the other risk models (C-statistic 0.71 versus 0.64-0.66). In conclusion, in our ACS population, the HAS-BLED risk score showed a fairly good predictive accuracy regarding in-hospital and follow-up bleeding events and in-hospital mortality. The use of renal dysfunction alternative criteria based on eGFR values resulted in out-of hospital mortality predictive accuracy enhancement.
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Huo Y, Jeong YH, Gong Y, Wang D, He B, Chen J, Fu G, Chen Y, Li J, Li Y, Goto S, Tantry US, Gurbel PA, Ahn JH, Kim HS, Ho Jeong M, Han Y, Smith SC, Ge J. 2018 update of expert consensus statement on antiplatelet therapy in East Asian patients with ACS or undergoing PCI. Sci Bull (Beijing) 2019; 64:166-179. [PMID: 36659616 DOI: 10.1016/j.scib.2018.12.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/17/2018] [Accepted: 12/07/2018] [Indexed: 01/21/2023]
Abstract
East Asians are the most populous race in the world and their health status is an important global issue. Compared with Caucasian populations, East Asian patients have a different benefit/risk ratio when using antithrombotic treatment. Despite this observation, treatment strategies in East Asian patients are mostly based on the American and European guidelines. Despite a lower platelet inhibitory response to clopidogrel, East Asian patients show a similar or even a lower rate of ischemic event occurrence and higher bleeding risk compared with Caucasian patients. For potent P2Y12 inhibitors (ticagrelor and prasugrel), East Asian patients have shown less favorable net clinical benefits compared with Caucasian patients, which may be related to differences in pharmacokinetic/pharmacodynamic profiles and therapeutic zone of antiplatelet effect. This updated consensus mainly focuses on state-of-the-art and current controversies in the East Asian population. In addition, when East Asian patients are administered potent P2Y12 receptor inhibitors, the strategies and ongoing trials to overcome the related hurdles are discussed.
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Affiliation(s)
- Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China.
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University, Changwon Hospital, Changwon 51472, Republic of Korea
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Daowen Wang
- Division of Cardiology, Internal Medicine Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital affiliated to Shanghai Jiaotong University, Shanghai 200030, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong General Hospital, Guangzhou 510080, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLAG General Hospital, Beijing 100853, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa 2591193, Japan
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA 22042, USA
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA 22042, USA
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University, Changwon Hospital, Changwon 51472, Republic of Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Myung Ho Jeong
- The Heart Research Center Nominated by Korea Ministry of Health and Welfare, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Junbo Ge
- Department of Cardiology, Fudan University Zhongshan Hospital, Shanghai 200032, China.
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Galimzhanov AM, Azizov BS. Ticagrelor for Asian patients with acute coronary syndrome in real-world practice: A systematic review and meta-analysis of observational studies. Indian Heart J 2019; 71:15-24. [PMID: 31000178 PMCID: PMC6477146 DOI: 10.1016/j.ihj.2019.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/02/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
| | - Baurzhan Slymovich Azizov
- University Hospital of State Medical University of Semey, Department of Endovascular Surgery, Semey, Kazakhstan
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De T, Park CS, Perera MA. Cardiovascular Pharmacogenomics: Does It Matter If You're Black or White? Annu Rev Pharmacol Toxicol 2018; 59:577-603. [PMID: 30296897 DOI: 10.1146/annurev-pharmtox-010818-021154] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Race and ancestry have long been associated with differential risk and outcomes to disease as well as responses to medications. These differences in drug response are multifactorial with some portion associated with genomic variation. The field of pharmacogenomics aims to predict drug response in patients prior to medication administration and to uncover the biological underpinnings of drug response. The field of human genetics has long recognized that genetic variation differs in frequency between ancestral populations, with some single nucleotide polymorphisms found solely in one population. Thus far, most pharmacogenomic studies have focused on individuals of European and East Asian ancestry, resulting in a substantial disparity in the clinical utility of genetic prediction for drug response in US minority populations. In this review, we discuss the genetic factors that underlie variability to drug response and known pharmacogenomic associations and how these differ between populations, with an emphasis on the current knowledge in cardiovascular pharmacogenomics.
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Affiliation(s)
- Tanima De
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - C Sehwan Park
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
| | - Minoli A Perera
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA;
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Brewster LM. Creatine kinase, energy reserve, and hypertension: from bench to bedside. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:292. [PMID: 30211180 PMCID: PMC6123196 DOI: 10.21037/atm.2018.07.15] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/11/2018] [Indexed: 12/17/2022]
Abstract
We hypothesized that human variation in the activity of the ATP regenerating enzyme creatine kinase (CK) activity affects hypertension and cardiovascular disease risk. CK is tightly bound close to ATP-utilizing enzymes including Ca2+-ATPase, myosin ATPase, and Na+/K+-ATPase, where it rapidly regenerates ATP from ADP, H+, and phosphocreatine. Thus, relatively high CK was thought to enhance ATP-demanding processes including resistance artery contractility and sodium retention, and reduce ADP-dependent functions. In a series of studies of our group and others, CK was linked to hypertension and bleeding risk. Plasma CK after rest, used as a surrogate measure for tissue CK, was associated with high blood pressure and failure of antihypertensive therapy in case-control and population studies. Importantly, high tissue CK preceded hypertension in animal models and in humans, and human vascular tissue CK gene expression was strongly associated with clinical blood pressure. In line with this, CK inhibition substantially reduced the contractility of human resistance arteries ex vivo. We also presented evidence that plasma CK reduced ADP-dependent platelet aggregation. In subsequent intervention studies, the oral competitive CK inhibitor beta-guanidinopropionic acid (GPA) reduced blood pressure in spontaneously hypertensive rats (SHRs), and a 1-week trial of sub-therapeutic dose GPA in healthy men was uneventful. Thus, based on theoretical concepts, evidence was gathered in laboratory, case-control, and population studies that high CK is associated with hypertension and with bleeding risk, potentially leading to a new mode of cardiovascular risk reduction with CK inhibition.
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Affiliation(s)
- Lizzy M Brewster
- Department of Cardiovascular Disease, Creatine Kinase Foundation, Amsterdam, The Netherlands
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Tang YD, Wang W, Yang M, Zhang K, Chen J, Qiao S, Yan H, Wu Y, Huang X, Xu B, Gao R, Yang Y, Yuan X, Ji H, Zhou Z, Liu Z, Chen J, Yuan J, Liu H, Qian J, Hu F, Shao C, Zhao H, Hua Y, Lu J. Randomized Comparisons of Double-Dose Clopidogrel or Adjunctive Cilostazol Versus Standard Dual Antiplatelet in Patients With High Posttreatment Platelet Reactivity. Circulation 2018; 137:2231-2245. [DOI: 10.1161/circulationaha.117.030190] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 01/17/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Yi-Da Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Wenyao Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Min Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Kuo Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Jing Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Shubin Qiao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Hongbing Yan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Yongjian Wu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Xiaohong Huang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Bo Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Runlin Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Yuejin Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
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Motovska Z, Bhatt DL. 12 months of DAPT after acute coronary syndrome still beats 6 months. Lancet 2018; 391:1240-1242. [PMID: 29544700 DOI: 10.1016/s0140-6736(18)30612-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Zuzana Motovska
- Division of Acute Cardiology Cardiocenter, Third Faculty of Medicine Charles University, University Hospital Kralovske Vinohrady, Srobarova, Prague 100 34, Czech Republic.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
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Niijima S, Ohmori T, Kario K. Differential impact of diabetes mellitus on antiplatelet effects of prasugrel and clopidogrel. Thromb J 2018; 16:5. [PMID: 29568240 PMCID: PMC5853094 DOI: 10.1186/s12959-017-0159-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Although prasugrel exerts stronger antiplatelet effects compared with clopidogrel, the factors affecting platelet reactivity under prasugrel have not been fully determined. This study aimed to find the novel mechanistic differences between two thienopyridines and identify the factor that influence platelet reactivity to each drug. Methods Forty patients with stable angina who underwent elective percutaneous coronary intervention were randomly assigned to receive either prasugrel (20 mg) or clopidogrel (300 mg) as a loading dose. Platelet function (light transmission, laser light scattering, and vasodilator-stimulated phosphoprotein phosphorylation) and plasma active metabolite levels were measured after the loading dose. Results Prasugrel consistently inhibited adenosine diphosphate receptor P2Y12 signalling to abolish amplification of platelet aggregation. Prasugrel abolished even small platelet aggregates composed of less than 100 platelets. On the other hand, clopidogrel inhibited large aggregates but increased small and medium platelet aggregates. Diabetes was the only independent variable for determining antiplatelet effects and active metabolite concentration of prasugrel, but not clopidogrel. Sleep-disordered breathing was significantly correlated with platelet reactivity in patients who had clopidogrel. Conclusions Prasugrel efficiently abolishes residual P2Y12 signalling that causes small platelet aggregates, but these small aggregates are not inhibited by clopidogrel. Considering the differential effect of diabetes on antiplatelet effects between these two drugs, the pharmacokinetics of prasugrel, other than cytochrome P450 metabolism, might be affected by diabetes. Trial registration UMIN-CTR UMIN000017624, retrospectively registered 21 May 2015.
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Affiliation(s)
- Satoshi Niijima
- 1Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Tsukasa Ohmori
- 2Department of Biochemistry, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Kazuomi Kario
- 1Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
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Kang J, Kim HS. The Evolving Concept of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention: Focus on Unique Feature of East Asian and "Asian Paradox". Korean Circ J 2018; 48:537-551. [PMID: 29968428 PMCID: PMC6031716 DOI: 10.4070/kcj.2018.0166] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/05/2018] [Indexed: 12/20/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is essential after percutaneous coronary intervention (PCI), while many studies have focused on determining the optimal degree of platelet inhibition and optimal DAPT duration to minimize complications after PCI. Current guidelines developed by the American College of Cardiology/American Heart Association and the European Society of Cardiology summarize previous studies and provide recommendations. However, these guidelines are mainly based on Western patients, and their characteristics might differ from those of East Asian patients. Previous data suggested that East Asian patients have unique features with regard to the response to antiplatelet agents. On comparing Western and East Asian patients, it was found that East Asian patients have a lower rate of ischemic events and higher rate of bleeding events after PCI, despite a higher on-treatment platelet reactivity, which is referred to as the “East Asian paradox.” As the main purpose of DAPT is to minimize ischemic and bleeding complications after PCI, these differences should be clarified before adopting the guidelines for East Asian patients. Therefore, in this article, we will review various issues regarding DAPT in East Asian patients, with a focus on the unique characteristics of East Asian patients, previous studies regarding antiplatelet agents in East Asian patients, and a guideline from an East Asian perspective.
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Affiliation(s)
- Jeehoon Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyo Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
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Choi HH, Lee JJ, Cho YD, Han MH, Cho WS, Kim JE, An SJ, Mun JH, Yoo DH, Kang HS. Antiplatelet Premedication for Stent-Assisted Coil Embolization of Intracranial Aneurysms: Low-Dose Prasugrel vs Clopidogrel. Neurosurgery 2017; 83:981-988. [PMID: 29301051 DOI: 10.1093/neuros/nyx591] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 11/20/2017] [Indexed: 12/11/2022] Open
Abstract
Abstract
BACKGROUND
The use of antiplatelet medications to prevent thrombosis in the treatment of cerebral aneurysms with stents has become widely emphasized.
OBJECTIVE
To compare low-dose prasugrel with clopidogrel in stent-assisted coil embolization of intracranial aneurysms.
METHODS
This is a retrospective review of 311 aneurysms from 297 patients who underwent stent-assisted endovascular coil embolization of unruptured intracranial aneurysm between November 2014 and March 2017. Thromboembolic and hemorrhagic adverse events were compared between 207 patients who received low-dose prasugrel (PSG group) and 90 patients who received clopidogrel (CPG group).
RESULTS
P2Y12 reaction unit (PRU) values were significantly lower in the PSG group (PSG group vs CPG group, 132.3 ± 76.9 vs 238.1 ± 69.1; P < .001); the percentage of inhibition was also statistically higher in the PSG group (54.0 ± 26.0% vs 20.8 ± 18.6%; P < .001). Thromboembolic events occurred less frequently in the PSG group than in the CPG group (0.9% vs 6.4%; P = .01), whereas there was no significant difference in the percentage of hemorrhagic complications (0.5% vs 2.2%; P = .22). In the multivariate analysis, clopidogrel as the antiplatelet medication was the sole significant risk factor for thromboembolism in this series of patients undergoing stent-assisted coil embolization.
CONCLUSION
Use of low-dose PSG as an antiplatelet premedication is quick, effective, and safe for stent-assisted coil embolization of unruptured intracranial aneurysms. Prasugrel premedication significantly lowered the frequency of thromboembolic events without increasing the risk of hemorrhage.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Dongk-uk University Hospital, Dongkuk Unive-rsity College of Medicine, Ilsan, Korea
| | - Jung Jun Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Joon An
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hyeon Mun
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Kwon TJ, Tantry US, Park Y, Choi YM, Ahn JH, Kim KH, Koh JS, Park JR, Hwang SJ, Kwak CH, Hwang JY, Gurbel PA, Smith SC, Jeong YH. Influence of platelet reactivity on BARC classification in East Asian patients undergoing percutaneous coronary intervention. Thromb Haemost 2017; 115:979-92. [DOI: 10.1160/th15-05-0366] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 12/28/2015] [Indexed: 11/05/2022]
Abstract
SummaryAn increasing body of data suggests that East Asian patients have differing risk profiles for both thrombophilia and bleeding compared with Western population. This study was designed to evaluate the relationship of bleeding to platelet function in East Asians undergoing percutaneous coronary intervention (PCI). Patients who had undergone uneventful PCI (n= 301) were prospectively enrolled and bleeding events were evaluated during dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. Platelet function was measured during hospitalisation and at 30-day follow-up by light transmittance aggregometry (LTA) and vasodilator-stimulated phosphoprotein phosphorylation (VASP-P) assay. During 30-day follow-up, 29.2 % of patients (n=88) experienced post-discharge Bleeding Academic Research Consortium (BARC) complications (24.6 % and 7.0 % of BARC type 1 and 2, respectively). Patients presenting with acute myocardial infarction had fewer episodes of type 1 BARC bleeding (odds ratio: 0.41; 95 % confidence interval: 0.22 to 0.76; p= 0.005). The cut-off of low platelet reactivity (LPR) (20 μM ADP-induced platelet aggregation ≤ 46.1 %; platelet reactivity index ≤ 45.1 %) was the independent determinant of type 2 BARC bleeding (odds ratio: 3.55 and 4.44; p= 0.009 and 0.002, respectively). The first 30-day BARC bleeding episodes were associated with an increased rate of subsequent premature DAPT discontinuation during one-year follow-up (4.7 % vs 11.4 %; odds ratio: 2.60; 95 % confidence interval: 1.04 to 6.50; p= 0.035). In conclusion, among East Asians, mild bleeding episodes are common early after PCI and are associated with premature DAPT discontinuation. Type 2 BARC bleeding episodes are associated with LPR cut-offs measured at 30 days post-discharge.
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Lee CH, Cheng CL, Kao Yang YH, Chao TH, Chen JY, Li YH. Cardiovascular and Bleeding Risks in Acute Myocardial Infarction Newly Treated With Ticagrelor vs. Clopidogrel in Taiwan. Circ J 2017; 82:747-756. [PMID: 29081474 DOI: 10.1253/circj.cj-17-0632] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are few data on ticagrelor in Asian patients. This study evaluated clinical outcomes with ticagrelor and clopidogrel in Taiwanese patients with acute myocardial infarction (AMI).Methods and Results:We used the Taiwan National Health Insurance Research Database to identify 27,339 AMI patients aged ≥18 years between January 2012 and December 2014, and only patients who survived greater than or equal to 30 days after AMI and took dual antiplatelet therapy were included. Cohorts of ticagrelor and clopidogrel were matched 1:8, based on propensity score matching, to balance baseline covariates. The primary efficacy endpoints were death from any cause, AMI, or stroke. The safety endpoints consisted of major gastrointestinal bleeding or intracerebral hemorrhage. Following propensity matching, the primary efficacy endpoint rate was 22% lower in the ticagrelor group than in the clopidogrel group (10.6% and 16.2%, respectively; adjusted HR, 0.779; 95% CI: 0.684-0.887). The safety endpoint rate was similar between the ticagrelor and clopidogrel groups (3.2% and 4.1% respectively; adjusted HR, 0.731; 95% CI: 0.522-1.026). CONCLUSIONS In real-world AMI Taiwanese patients, ticagrelor seemed to offer better anti-ischemic protection than clopidogrel, without an increase in the rate of major bleeding. A large-scale randomized trial is needed to assess the efficacy and safety of ticagrelor in East Asian AMI patients.
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Affiliation(s)
- Cheng-Han Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Ching-Lan Cheng
- Department of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University
| | - Yea-Huei Kao Yang
- Department of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Ju-Yi Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
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Koshizaka M, Lopes RD, Newby LK, Clare RM, Schulte PJ, Tricoci P, Mahaffey KW, Ogawa H, Moliterno DJ, Giugliano RP, Huber K, James S, Harrington RA, Alexander JH. Obesity, Diabetes, and Acute Coronary Syndrome: Differences Between Asians and Whites. Am J Med 2017; 130:1170-1176. [PMID: 28396226 DOI: 10.1016/j.amjmed.2017.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Most diabetes and cardiovascular studies have been conducted in white patients, with data being extrapolated to other population groups. METHODS For this analysis, patient-level data were extracted from 5 randomized clinical trials in patients with acute coronary syndrome; we compared obesity levels between Asian and white populations, stratified by diabetes status. By using an adjusted Cox proportional hazards model, hazard ratios (HRs) for cardiovascular outcomes after an acute coronary syndrome were determined. RESULTS We identified 49,224 patient records from the 5 trials, with 3176 Asians and 46,048 whites. Whites with diabetes had higher body mass index values than those without diabetes (median 29.3 vs 27.2 kg/m2; P < .0001), whereas Asians with diabetes and without diabetes had similar body mass index (24.7 vs 24.2 kg/m2). Asians with diabetes (HR, 1.63; 95% confidence interval [CI], 1.32-2.02), whites with diabetes (HR, 1.15; 95% CI, 1.06-1.25), and Asians without diabetes (HR, 1.36; 95% CI, 1.14-1.64) had higher rates of the composite of death, myocardial infarction, or stroke at 30 days than whites without diabetes. Asians with diabetes (HR, 1.84; 95% CI, 1.47-2.31), whites with diabetes (HR, 1.47; 95% CI, 1.33-1.62), and Asians without diabetes (HR, 1.38; 95% CI, 1.11-1.73) had higher rates of death at 1 year compared with whites without diabetes. There were no significant interactions between race and diabetes for ischemic outcomes. CONCLUSIONS Although Asians with diabetes and acute coronary syndrome are less likely to be obese than their white counterparts, their risk for death or recurrent ischemic events was not lower.
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Affiliation(s)
- Masaya Koshizaka
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Division of Diabetes, Metabolism and Endocrinology, Clinical Research Center, Chiba University Hospital, Japan.
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Robert M Clare
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Phillip J Schulte
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Hisao Ogawa
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Boston, Mass
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Private University, Medical School, Vienna, Austria
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University and Uppsala Clinical Research Center, Sweden
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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50
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Hilkens NA, Algra A, Diener HC, Reitsma JB, Bath PM, Csiba L, Hacke W, Kappelle LJ, Koudstaal PJ, Leys D, Mas JL, Sacco RL, Amarenco P, Sissani L, Greving JP. Predicting major bleeding in patients with noncardioembolic stroke on antiplatelets: S 2TOP-BLEED. Neurology 2017; 89:936-943. [PMID: 28768848 DOI: 10.1212/wnl.0000000000004289] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/01/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To develop and externally validate a prediction model for major bleeding in patients with a TIA or ischemic stroke on antiplatelet agents. METHODS We combined individual patient data from 6 randomized clinical trials (CAPRIE, ESPS-2, MATCH, CHARISMA, ESPRIT, and PRoFESS) investigating antiplatelet therapy after TIA or ischemic stroke. Cox regression analyses stratified by trial were performed to study the association between predictors and major bleeding. A risk prediction model was derived and validated in the PERFORM trial. Performance was assessed with the c statistic and calibration plots. RESULTS Major bleeding occurred in 1,530 of the 43,112 patients during 94,833 person-years of follow-up. The observed 3-year risk of major bleeding was 4.6% (95% confidence interval [CI] 4.4%-4.9%). Predictors were male sex, smoking, type of antiplatelet agents (aspirin-clopidogrel), outcome on modified Rankin Scale ≥3, prior stroke, high blood pressure, lower body mass index, elderly, Asian ethnicity, and diabetes (S2TOP-BLEED). The S2TOP-BLEED score had a c statistic of 0.63 (95% CI 0.60-0.64) and showed good calibration in the development data. Major bleeding risk ranged from 2% in patients aged 45-54 years without additional risk factors to more than 10% in patients aged 75-84 years with multiple risk factors. In external validation, the model had a c statistic of 0.61 (95% CI 0.59-0.63) and slightly underestimated major bleeding risk. CONCLUSIONS The S2TOP-BLEED score can be used to estimate 3-year major bleeding risk in patients with a TIA or ischemic stroke who use antiplatelet agents, based on readily available characteristics. The discriminatory performance may be improved by identifying stronger predictors of major bleeding.
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Affiliation(s)
- Nina A Hilkens
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France.
| | - Ale Algra
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Hans-Christoph Diener
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Johannes B Reitsma
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Philip M Bath
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Laszlo Csiba
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Werner Hacke
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - L Jaap Kappelle
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Peter J Koudstaal
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Didier Leys
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Jean-Louis Mas
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Ralph L Sacco
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Pierre Amarenco
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Leila Sissani
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
| | - Jacoba P Greving
- From the Julius Center for Health Sciences and Primary Care (N.A.H., A.A., J.B.R., J.P.G.) and Department of Neurology and Neurosurgery (A.A., L.J.K.), Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Department of Neurology (H.-C.D.), University Hospital Essen, Germany; Stroke Trials Unit (P.M.B.), Division of Clinical Neuroscience, University of Nottingham, UK; Department of Neurology (L.C.), University of Debrecen Medical and Health Science Center, Hungary; Department of Neurology (W.H.), University of Heidelberg, Germany; Department of Neurology (P.J.K.), Erasmus Medical Center, Rotterdam, the Netherlands; Department of Neurology (D.L.), Roger Salengro Hospital, Lille, France; Department of Neurology (J.-L.M.), Hôpital Sainte-Anne, Université Paris Descartes, France; Department of Neurology (R.L.S.), Miller School of Medicine, University of Miami, FL; and Department of Neurology and Stroke Center (P.A., L.S.), Bichat University Hospital, Paris, France
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