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Khalid AR, Ahmad F, Naeem MAB, Ahmed S, Umar M, Mehmood H, Kashif M, Ali S. Safety of Clopidogrel vs. Ticagrelor in Dual Antiplatelet Therapy Regimens for High-Bleeding Risk Acute Coronary Syndrome Patients: A Comprehensive Meta-analysis of Adverse Outcomes. High Blood Press Cardiovasc Prev 2024; 31:141-155. [PMID: 38557855 DOI: 10.1007/s40292-024-00635-3] [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: 12/07/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Patients of acute coronary syndrome (ACS) at a high-bleeding risk (HBR) often require dual antiplatelet therapy (DAPT) to reduce the risk of recurrent cardiovascular events. Clopidogrel and ticagrelor are the most commonly used antiplatelet agents in DAPT regimens. However, the safety profiles of these drugs in ACS patients at HBR remain a subject of ongoing debate. AIM To investigate any difference between the safety of clopidogrel and ticagrelor used as a part of DAPT regimen in ACS patients at HBR. METHODS A systematic search on PubMed, Cochrane Library, and Google Scholar was conducted to identify experimental and observational studies published up to the knowledge cutoff date in September 2023. Studies comparing the safety of clopidogrel and ticagrelor in ACS patients at HBR were included for analysis. The primary outcomes assessed were major bleeding events, stroke, and myocardial infarction (MI), while secondary outcomes included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and net adverse clinical and cerebral events (NACCE). RESULTS We included a total of 8 observational studies in our meta-analysis. The pooled analysis revealed a statistically significant increase in the risk of MI (pooled RR = 1.43; 95% CI 1.12-1.83; P = 0.005) in the patients using clopidogrel. There were no statistically significant differences in major bleeding events (pooled RR = 0.94; 95% CI 0.82-1.09; P = 0.44), stroke (pooled RR = 1.36; 95% CI 0.86-2.14; P = 0.18), all-cause mortality (pooled RR = 1.17; 95% CI 0.97-1.41; P = 0.10), MACCE (pooled RR = 1.07; 95% CI 0.76-1.50; P = 0.69) and NACCE (pooled RR = 0.95; 95% CI 0.66-1.37; P = 0.78) between the two groups. Subgroup analyses based on region were performed. CONCLUSION Both drugs are generally safe for treating ACS patients with HBR at baseline, although a higher risk of MI was observed with the use of clopidogrel. Nevertheless, drug choice should factor in regional variations, patient-specific characteristics, cost, accessibility, and potential drug interactions.
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Affiliation(s)
| | - Farooq Ahmad
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | - Smak Ahmed
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Muhammad Umar
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | | | - Shazib Ali
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
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Amoafo EB, Entsie P, Kang Y, Canobbio I, Liverani E. Platelet P2Y 12 signalling pathway in the dysregulated immune response during sepsis. Br J Pharmacol 2024; 181:532-546. [PMID: 37525937 PMCID: PMC10830899 DOI: 10.1111/bph.16207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
Sepsis is a complicated pathological condition in response to severe infection. It is characterized by a strong systemic inflammatory response, where multiple components of the immune system are involved. Currently, there is no treatment for sepsis. Blood platelets are known for their role in haemostasis, but they also participate in inflammation through cell-cell interaction and the secretion of inflammatory mediators. Interestingly, an increase in platelet activation, secretion, and aggregation with other immune cells (such as monocytes, T-lymphocytes and neutrophils) has been detected in septic patients. Therefore, antiplatelet therapy in terms of P2Y12 antagonists has been evaluated as a possible treatment for sepis. It was found that blocking P2Y12 receptors decreased platelet marker expression and limited attachment to immune cells in some studies, but not in others. This review addresses the role of platelets in sepsis and discusses whether antagonizing P2Y12 signalling pathways can alter the disease outcome. Challenges in studying P2Y12 antagonists in sepsis also are discussed. LINKED ARTICLES: This article is part of a themed issue on Platelet purinergic receptor and non-thrombotic disease. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.4/issuetoc.
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Affiliation(s)
- Emmanuel Boadi Amoafo
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Philomena Entsie
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Ying Kang
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Ilaria Canobbio
- Department of Biology and Biotechnology, University of Pavia, Pavia, Italy
| | - Elisabetta Liverani
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
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Zhou S, Li W, Xiang Q, Wang Z, Zhang H, Mu G, Liu Z, Cui Y. Optimal anti-platelet therapy for older patients with acute coronary syndrome: a network meta-analysis of randomized trials comprising 59,284 older patients. J Thromb Thrombolysis 2024; 57:143-154. [PMID: 37548902 PMCID: PMC10830599 DOI: 10.1007/s11239-023-02875-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
The aim of this study was to identify the optimal anti-platelet therapy in older acute coronary syndrome (ACS) patients with a mean age ≥ 60 years by comparing the efficacy and safety of different anti-platelet therapies. The selection of antiplatelet therapy in older patients with ACS is a clinical challenge. Numerous evidences indicate that the de-escalation of dual anti-platelet therapy (DAPT) or P2Y12 inhibitor monotherapy may reduce bleeding risk without increasing thrombotic events. However, there is a lack of systematic reviews and optimal strategy analysis regarding older ACS patients. Randomized controlled trials (RCTs) of anti-platelet therapy in older ACS patients were identified. Major adverse cardiovascular events (MACE) were the primary outcome. Secondary outcomes included all death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and trial-defined major bleeding. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on posterior probability. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. A total of 12 RCTs including 59,284 older ACS patients treated with five anti-platelet strategies were included. Ticagrelor monotherapy after 3 months DAPT was comparable to the other strategies (OR 0.73; 95% CI 0.32-1.6) in terms of MACE risk. Additionally, P score analysis and SUCRA Bayesian analysis showed that it was the most beneficial treatment for all deaths, cardiovascular death and revascularization. For safety, although there was no significant difference in direct comparisons, both SUCRA Bayesian (0.806) and P score (0.519) analysis suggested that ticagrelor monotherapy was the safest strategy. The current evidence demonstrated that ticagrelor monotherapy after 3 months DAPT may be a promising approach for achieving a more favorable balance between risk and benefit for older ACS patients, with a relatively low bleeding risk and without an increased risk of MACE events. Moreover, it remains the preferred option for clinical outcomes such as all death, CV death and revascularization. Further high-quality and long-term studies are required to validate anti-platelet therapies among older ACS patients.
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Affiliation(s)
- Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Wenhui Li
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
- Institute of Clinical Pharmacology, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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Fujisaki T, Kuno T, Iwagami M, Miyamoto Y, Takagi H, Deharo P, Cuisset T, Briasoulis A, Panaich S, Latib A, Kohsaka S. Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2023; 102:788-802. [PMID: 37675959 DOI: 10.1002/ccd.30811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients. METHODS PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding. RESULTS Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y12 inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies. CONCLUSIONS Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
- Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | | | - Sidakpal Panaich
- Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Chałupka J, Sikora A, Ziegler-Borowska M, Marszałł MP. Bio-Approach for Obtaining Enantiomerically Pure Clopidogrel with the Use of Ionic Liquids. Int J Mol Sci 2023; 24:11124. [PMID: 37446300 PMCID: PMC10342315 DOI: 10.3390/ijms241311124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Clopidogrel is a chiral compound widely used as an antiplatelet medication that lowers the risk of blood clots, strokes, and heart attacks. The main aim of the study presented herein was to obtain (S)-clopidogrel, which is commercially available in treatments, via the kinetic resolution of racemic clopidogrel carboxylic acid with the use of lipase from Candida rugosa and a two-phase reaction medium containing an ionic liquid. For this purpose, the enantioselective biotransformation of clopidogrel carboxylic acid and chiral chromatographic separation with the use of a UPLC-MS/MS system were optimized. The best kinetic resolution parameters were obtained by using a catalytic system containing lipase from Candida rugosa OF as a biocatalyst, cyclohexane and [EMIM][BF4] as a two-phase reaction medium, and methanol as an acyl acceptor. The enantiomeric excess of the product was eep = 94.21% ± 1.07 and the conversion was c = 49.60% ± 0.57%, whereas the enantioselectivity was E = 113.40 ± 1.29. The performed study proved the possibility of obtaining (S)-clopidogrel with the use of lipase as a biocatalyst and a two-phase reaction medium containing an ionic liquid, which is in parallel with green chemistry methodology and does not require environmentally harmful conditions.
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Affiliation(s)
- Joanna Chałupka
- Department of Medicinal Chemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dr. A. Jurasza 2, 85-089 Bydgoszcz, Poland; (J.C.); (M.P.M.)
| | - Adam Sikora
- Department of Medicinal Chemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dr. A. Jurasza 2, 85-089 Bydgoszcz, Poland; (J.C.); (M.P.M.)
| | - Marta Ziegler-Borowska
- Department of Biomedical Chemistry and Polymer Science, Faculty of Chemistry, Nicolaus Copernicus University in Torun, Gagarina 7, 87-100 Toruń, Poland;
| | - Michał Piotr Marszałł
- Department of Medicinal Chemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dr. A. Jurasza 2, 85-089 Bydgoszcz, Poland; (J.C.); (M.P.M.)
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Entsie P, Kang Y, Amoafo EB, Schöneberg T, Liverani E. The Signaling Pathway of the ADP Receptor P2Y12 in the Immune System: Recent Discoveries and New Challenges. Int J Mol Sci 2023; 24:ijms24076709. [PMID: 37047682 PMCID: PMC10095349 DOI: 10.3390/ijms24076709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
P2Y12 is a G-protein-coupled receptor that is activated upon ADP binding. Considering its well-established role in platelet activation, blocking P2Y12 has been used as a therapeutic strategy for antiplatelet aggregation in cardiovascular disease patients. However, receptor studies have shown that P2Y12 is functionally expressed not only in platelets and the microglia but also in other cells of the immune system, such as in monocytes, dendritic cells, and T lymphocytes. As a result, studies were carried out investigating whether therapies targeting P2Y12 could also ameliorate inflammatory conditions, such as sepsis, rheumatoid arthritis, neuroinflammation, cancer, COVID-19, atherosclerosis, and diabetes-associated inflammation in animal models and human subjects. This review reports what is known about the expression of P2Y12 in the cells of the immune system and the effect of P2Y12 activation and/or inhibition in inflammatory conditions. Lastly, we will discuss the major problems and challenges in studying this receptor and provide insights on how they can be overcome.
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Affiliation(s)
- Philomena Entsie
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
| | - Ying Kang
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
| | - Emmanuel Boadi Amoafo
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
| | - Torsten Schöneberg
- Division of Molecular Biochemistry, Rudolf Schönheimer Institute of Biochemistry, Medical Faculty, Leipzig University, 04103 Leipzig, Germany
| | - Elisabetta Liverani
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
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Yeh JS, Chen WT, Tomlinson B, Tam WC, Chien LN. Comparing the effectiveness and safety of dual antiplatelet with ticagrelor or clopidogrel in elderly Asian patients with acute myocardial infraction. Front Cardiovasc Med 2023; 10:1143509. [PMID: 37008324 PMCID: PMC10060791 DOI: 10.3389/fcvm.2023.1143509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
BackgroundCurrent guidelines recommend potent P2Y12 inhibitors for patients after acute coronary syndrome. However, the data on the efficacy and safety of potent P2Y12 inhibitors in elderly Asian populations was limited. We aimed to investigate the major adverse cardiovascular events (MACE), bleeding events, and net adverse clinical events (NACE) with ticagrelor and clopidogrel in Taiwanese patients aged 65 and older after acute myocardial infarction (AMI).MethodsThis retrospective population-based cohort study was conducted using data from the National Health Insurance Research Database. The AMI patients aged ≥65 years who underwent percutaneous coronary intervention (PCI) and survived after 1 month were included. The patients were separated into 2 cohorts depending on the type of dual antiplatelet therapy (DAPT) they received: ticagrelor plus aspirin (T + A) or clopidogrel plus aspirin (C + A). We used inverse probability of treatment weighting to balance the difference between these 2 study groups. The outcome included all-cause mortality, MACE (cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction), intracerebral hemorrhage, major bleeding, and NACE which is composed of cardiovascular death, ischemic and hemorrhagic events. The follow-up period was up to 12 months.ResultsFrom 2013 to 2017, a total of 14,715 patients who met the eligibility criteria were separated into 2 groups: 5,051 for T + A and 9,664 for C + A. Compared to patients with C + A, patients who received T + A had a lower risk of cardiovascular death and all-cause death, with an adjusted HR of 0.57 [95% confidence interval (CI), 0.38–0.85, p = 0.006] and 0.58 (95% CI 0.45–0.74, p < 0.001), respectively. No differences were found in MACE, intracranial and major bleeding between the 2 groups. In addition, the patients with T + A had a lower risk of NACE with an adjusted HR of 0.86 (95% CI 0.74–1.00, p = 0.045)ConclusionAmong elderly AMI patients receiving DAPT after successful PCI, ticagrelor was a more favorable P2Y12 inhibitor than clopidogrel because of lowering the risk of death and NACE without increasing the risk of severe bleeding. Ticagrelor is an effective and safe P2Y12 inhibitor in Asian elderly survivors after PCI.
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Affiliation(s)
- Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Ting Chen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macao SAR, China
| | - Weng-Chio Tam
- Department of Cardiology, Centro Hospitalar Conde São Januário, Macao SAR, China
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Correspondence: Li-Nien Chien
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Ijaz SH, Baron SJ, Shahnawaz A, Kulbak G, Levy M, Resnic F, Ganatra S, Dani SS. Utilization Trends In Platelet Adenosine Diphosphate P2Y12 Receptor Inhibitor and Cost Among Medicare Beneficiaries. Curr Probl Cardiol 2023; 48:101608. [PMID: 36690313 DOI: 10.1016/j.cpcardiol.2023.101608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023]
Abstract
Recent guidelines regarding acute coronary syndrome (ACS) have advocated for use of prasugrel and ticagrelor over clopidogrel for acute coronary syndrome. However, analyses from multiple databases have shown that clopidogrel continues to be the most commonly prescribed P2Y12 inhibitor. We aimed to evaluate the trends in utilization and cost of P2Y12 inhibitors for Medicare beneficiaries using data from Medicare Part D Prescription Drug Data Event set from 2011 to 2018 for P2Y12 inhibitors. Medicare part D total beneficiaries for P2Y12 receptor inhibitors increased from 2011 to 2018 by 34.8% from 2.45 million to 3.31 million. The total cost for P2Y12 antiplatelets decreased from $ 3.72 billion in 2011 to $ 0.72 billion in 2018 by 80.4%. The availability of generic clopidogrel drove the considerable total cost reduction. Clopidogrel was the most prescribed P2Y12 inhibitor since its introduction accounting for more than 90% of the Medicare beneficiaries from 2013 to 2018. Overall, the number of beneficiaries on newer P2Y12 inhibitors showed a steady increase with 5.9% beneficiaries on brilinta in 2018 and 2.1 % on prasugrel. The total cost of brilinta beneficiaries grew exponentially accounting for 59.2% of total cost in 2018 and average cost per beneficiary increased by 465% in study period. Despite the availability of generic version clopidogrel and prasugrel, 2,161,175 beneficiaries were on brand plavix and 87,174 on effient which contributed to the increased total expenditure. Earlier introduction and transition to generic versions of medication may help to reduce the drug cost and potentially enhance medication compliance.
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Affiliation(s)
- Sardar Hassan Ijaz
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA.
| | - Suzanne J Baron
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
| | | | - Guy Kulbak
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
| | - Michael Levy
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
| | - Frederic Resnic
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
| | - Sarju Ganatra
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
| | - Sourbha S Dani
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
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Zhang Y, Peng W, Shi X, Han J, Wang Y, Fang Z, Lin Y. Ticagrelor vs. Clopidogrel in Older Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Insights From a Real-World Registry. Front Cardiovasc Med 2022; 9:859962. [PMID: 35369358 PMCID: PMC8964993 DOI: 10.3389/fcvm.2022.859962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives It is unclear whether more potent P2Y12 inhibitors are of benefit to older patients who are at high risk for both ischemia and bleeding. We conducted an observational study to compare the clinical outcomes of clopidogrel and ticagrelor uses in older patients with an acute coronary syndrome (ACS). Methods Older patients (aged ≥65 years) with ACS who underwent percutaneous coronary intervention (PCI) were divided into clopidogrel-treated and ticagrelor-treated groups. The primary observational endpoint was the occurrence of net adverse clinical and cerebral events (NACCEs) during a 12-month period, which is defined as the composite endpoint of all-cause death, myocardial infarction (MI), stroke, stent thrombosis, urgent coronary revascularization, and clinically significant bleeding. The secondary endpoints were clinically significant bleeding and major adverse clinical and cerebral events (MACCEs). Results This study included a total of 2,611 patients. Of them, 1,636 received clopidogrel and 975 received ticagrelor. Between patients receiving clopidogrel and those receiving ticagrelor, no significant differences were noted in NACCE (8.4 vs. 9.7%, respectively; adjusted hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66-1.12) or MACCE (7.1 vs. 7.0%, respectively; adjusted HR, 1.13; 95% CI, 0.83-1.55) during the 12-month follow-up period. In contrast, the occurrence of clinically significant bleeding was significantly less in clopidogrel-treated patients compared with that in ticagrelor-treated patients (27, 1.7%, vs. 31, 3.2%, respectively; adjusted HR, 0.42; 95% CI, 0.25-0.69). Stratified analyses revealed no significant association between age (≥75 years vs. <75 years) and treatment condition in terms of primary or secondary endpoints. Conclusion This study showed that clopidogrel and ticagrelor had comparable net clinical benefits in patients with ACS aged ≥65 years. Additionally, clopidogrel was associated with a significantly lower risk of major bleeding than ticagrelor without an increase in ischemic risk. These findings suggest that clopidogrel is an effective alternative to the more potent P2Y12 inhibitor ticagrelor in older patients.
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Affiliation(s)
- Yunnan Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Wenxing Peng
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiujin Shi
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jialun Han
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yifan Wang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Zhenwei Fang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
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Byun S, Choo EH, Oh GC, Lim S, Choi IJ, Lee KY, Lee SN, Hwang BH, Kim CJ, Park MW, Park CS, Kim HY, Yoo KD, Jeon DS, Youn HJ, Chung WS, Kim MC, Jeong MH, Yim HW, Ahn Y, Chang K. Temporal Trends of Major Bleeding and Its Prediction by the Academic Research Consortium-High Bleeding Risk Criteria in Acute Myocardial Infarction. J Clin Med 2022; 11:jcm11040988. [PMID: 35207261 PMCID: PMC8875601 DOI: 10.3390/jcm11040988] [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: 12/30/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 12/01/2022] Open
Abstract
Limited data exist on the temporal trend of major bleeding and its prediction by the Academic Research Consortium-High Bleeding Risk (ARC-HBR) criteria in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI). We investigated 10-year trends of major bleeding and predictive ability of the ARC-HBR criteria in AMI patients. In a multicenter registry of 10,291 AMI patients undergoing PCI between 2004 and 2014 the incidence of Bleeding Academic Research Consortium (BARC) 3 and 5 bleeding was assessed, and, outcomes in ARC-defined HBR patients with AMI were compared with those in non-HBR. The primary outcome was BARC 3 and 5 bleeding at 1 year. Secondary outcomes included all-cause mortality and composite of cardiovascular death, myocardial infarction, or ischemic stroke. The annual incidence of BARC 3 and 5 bleeding in the AMI population has increased over the years (1.8% to 5.8%; p < 0.001). At 1 year, ARC-defined HBR (n = 3371, 32.8%) had significantly higher incidence of BARC 3 and 5 bleeding (9.8% vs. 2.9%; p < 0.001), all-cause mortality (22.8% vs. 4.3%; p < 0.001) and composite of ischemic events (22.6% vs. 5.8%; p < 0.001) compared to non-HBR. During the past decade, the incidence of major bleeding in the AMI population has increased. The ARC-HBR criteria provided reliable predictions for major bleeding, mortality, and ischemic events in AMI patients.
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Affiliation(s)
- Sungwook Byun
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.B.); (H.-Y.K.)
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Gyu-Chul Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.J.K.)
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (I.J.C.); (D.S.J.)
| | - Kwan Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Su Nam Lee
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.N.L.); (K.-D.Y.)
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.J.K.)
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Chul Soo Park
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Hee-Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.B.); (H.-Y.K.)
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.N.L.); (K.-D.Y.)
| | - Doo Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (I.J.C.); (D.S.J.)
| | - Ho Joong Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Wook Sung Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju 61469, Korea; (M.C.K.); (M.H.J.); (Y.A.)
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju 61469, Korea; (M.C.K.); (M.H.J.); (Y.A.)
| | - Hyeon-Woo Yim
- Clinical Research Coordinating Center, Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju 61469, Korea; (M.C.K.); (M.H.J.); (Y.A.)
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
- Correspondence: ; Tel.: +82-2-2258-1139
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Coronary Heart Disease (CHD) in Elderly Patients: Which Drug to Choose, Ticagrelor and Clopidogrel? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Dev Dis 2021; 8:jcdd8100123. [PMID: 34677192 PMCID: PMC8538993 DOI: 10.3390/jcdd8100123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/13/2021] [Accepted: 09/24/2021] [Indexed: 01/08/2023] Open
Abstract
Background: A new generation P2Y12 receptor inhibitor (ticagrelor) is recommended in current therapeutic guidelines to treat patients with coronary heart disease (CHD). However, it is unknown if ticagrelor is more effective than clopidogrel in elderly patients. Therefore, a systematic review was done to assess the effectiveness and safety of ticagrelor and clopidogrel in older patients with CHD to determine the appropriate antiplatelet treatment plan. Methodology: We performed a systematic review of randomized controlled trials (RCTs) to compare the effectiveness and safety of ticagrelor vs. clopidogrel in elderly patients with CHD. We selected eligible RCTs based on specified study criteria following a systematic search of PubMed and Scopus databases from January 2007 to May 2021. Primary efficacy outcomes assessed were major adverse cardiovascular events (MACEs), myocardial infarction (MI), stent thrombosis (ST), and all-cause death. The secondary outcome assessed was major bleeding events. We used RevMan 5.3 software to conduct a random-effects meta-analysis and estimated the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs) for ticagrelor and clopidogrel. Results: Data from 6 RCTs comprising 21,827 elderly patients were extracted according to the eligibility criteria. There was no significant difference in the MACE outcome (incidence: 9.23% vs. 10.57%; RR = 0.95, 95% CI = 0.70–1.28, p = 0.72), MI (incidence: 5.40% vs. 6.23%; RR = 0.94, 95% CI= 0.69–1.27, p = 0.67), ST (incidence: 2.33% vs. 3.17%; RR = 0.61, 95% CI= 0.32–1.17, p = 0.13), and all-cause death (4.29% vs. 5.33%; RR = 0.86, 95% CI = 0.65–1.12, p = 0.25) for ticagrelor vs. clopidogrel, respectively. In addition, ticagrelor was not associated with a significant increase in the rate of major bleeding (incidence: 9.98% vs. 9.33%: RR = 1.37, 95% CI = 0.97–1.94, p = 0.07) vs. clopidogrel. Conclusions: This study did not find evidence that ticagrelor is significantly more effective or safer than clopidogrel in elderly patients with CHD.
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Verdoia M, Barbieri L, De Luca G. Antiplatelet therapy in ACS elderly patients: Another piece of this intriguing puzzle. Int J Cardiol 2021; 334:28-29. [PMID: 33915235 DOI: 10.1016/j.ijcard.2021.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Monica Verdoia
- Division of Cardiology Ospedale degli Infermi, ASL Biella, Italy; Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Policlinico of Milan, Milan, Italy
| | - Giuseppe De Luca
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy; Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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