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Senguttuvan NB, Sankaran R, Rajeev Y, Thaiyal D, Mathew A, Dharsini K, Marcelene D, Kalsingh MJ, Sahu SK, Sampath A, Prem Kumar KJ, Parthasarathy H, Louis A, Gnanaraj A, Reddy KN, Abraham KA. Effect of discontinuation of ticagrelor and switching-over to other P2Y12 agents in patients with acute coronary syndrome: a single-center real-world experience from India. Egypt Heart J 2021; 73:7. [PMID: 33428005 PMCID: PMC7801539 DOI: 10.1186/s43044-020-00128-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/16/2020] [Indexed: 12/31/2022] Open
Abstract
Background Dual antiplatelet therapy is the current standard of care after acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). We intended to study the pattern of use of ticagrelor in patients with acute coronary syndrome undergoing PCI and the effect of switching over to other P2Y12 receptor inhibition on clinical outcomes. Results All patients aged > 18 years who had been admitted with acute coronary syndrome and had been provided ticagrelor as the second antiplatelet agent were included as study participants. The primary outcome of the study was the composite outcome of death, recurrent myocardial infarctions, re-intervention, and major bleeding. We studied 321 patients (54 female patients, 16.82%). The mean age of the patients was 56.65 ± 11.01 years. Ticagrelor was stopped in 76.7% on follow-up. It was stopped in 6.3%, 13.5%, 13.1%, 21.9%, and 45.1% of patients during the first month but after discharge, between first and third months, between 3 and 6 months, between 6 and 12 months, and after 12 months, respectively. In the majority of patients, ticagrelor was replaced by clopidogrel (97.9%). It was stopped according to the physician’s discretion in 79.3% of patients, whereas it was the cost of the drug that made the patient to get swapped to another agent in 18.6%. No difference in the primary composite outcome was observed between the groups where ticagrelor was continued post 12 months and ticagrelor was continued and ticagrelor was switched-over to another agent. Similarly, no difference in death, recurrent myocardial infarctions, re-interventions, or major bleeding manifestations was observed between the two groups. Conclusion In patients with acute coronary syndrome who undergo PCI, we observed that early discontinuation of ticagrelor and switching over to other P2Y12 inhibitors after discharge did not affect clinical outcomes.
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Affiliation(s)
- Nagendra Boopathy Senguttuvan
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. .,Adjunct Faculty-Indian Institute of Technology Madras, Chennai, Tamil Nadu, India. .,Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India.
| | - Ramesh Sankaran
- Department of Cardiology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Yashasvi Rajeev
- Department of Cardiology, Jaswant Rai Specialty Hospitals, Chennai, Tamil Nadu, India
| | - Devi Thaiyal
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - Angel Mathew
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - K Dharsini
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - Divya Marcelene
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | | | - Sujit Kumar Sahu
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - Aravind Sampath
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - K J Prem Kumar
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | | | - Amal Louis
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - Anand Gnanaraj
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - K N Reddy
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
| | - K A Abraham
- Department of Cardiology, Apollo Specialty Hospitals, Chennai, Tamil Nadu, India
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Pujade I, Perino J, Mathieu C, Arnaud M, Raschi E, Gatti M, Bezin J, Salvo F. Risk of bradyarrhythmia related to ticagrelor: A systematic review and meta-analysis. Pharmacol Res 2020; 160:105089. [PMID: 32687950 DOI: 10.1016/j.phrs.2020.105089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/01/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Ticagrelor was related to bradycardia in DISPERSE-II trial. This risk has been integrated into the European risk-management plan, and its use is warned in at-risk patients. Nevertheless, this risk was not systematically assessed nor measured. OBJECTIVES To estimate the risk of bradyarrhythmia associated with ticagrelor. STUDY DESIGN Systematic review and meta-analysis. DATA-SOURCE MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ISI web of Science, clinicaltrial.gov, clinicaltrialsregister.eu. STUDY SELECTION Randomized controlled trials (RCTs) and observational studies in patients treated with ticagrelor or comparator(s). META-ANALYSIS Risk of bias in each RCT was assessed using Cochrane tool. Relative Risks (RR) with 95 % confidence intervals (95 %CI) were calculated for each RCT, and pooled using fixed-effect or random-effects models, when appropriate. Subgroup and sensitivity analyses were performed. A potential publication bias was searched. RESULTS Among 82 eligible studies, event data were missing for 56 studies, due to detected reporting bias (i.e. inability to confirm zero events). Fifteen RCTs were selected and the combined RR of bradyarrhythmia was 1.15 (95 %CI 1.05-1.26), and 1.29 (1.02-1.65) for severe bradyarrhythmia. The risk appeared to be dose dependent. Restricting the analysis only to RCTs performed in patients without previous bradyarrhythmia resulted in a non-increased risk. CONCLUSION This meta-analysis confirmed the risk of bradyarrhythmia or severe bradyarrhythmia related to ticagrelor, and its use in patients without previous bradycardia was effective in preventing it. The evidence coming from this meta-analysis was low to moderate due to missing outcome in 2/3 of eligible studies. Waiting for access to these data, the use of ticagrelor in patients with risk factors of bradycardias should be avoided.
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Affiliation(s)
- Iris Pujade
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France
| | - Justine Perino
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France
| | - Clément Mathieu
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France
| | - Mickael Arnaud
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, I-40126, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, I-40126, Italy
| | - Julien Bezin
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France
| | - Francesco Salvo
- Univ Bordeaux, INSERM U1219, Pharmaco-epidemiology Team, Bordeaux, F-33000, France; CHU de Bordeaux, Bordeaux, F-33000, France.
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