1
|
Park Y, Koh JS, Lee JH, Park JH, Shin ES, Oh JH, Chun W, Lee SY, Bae JW, Kim JS, Kim W, Suh JW, Yang DH, Hong YJ, Chan MY, Kang MG, Park HW, Hwang SJ, Hwang JY, Ahn JH, Choi SW, Jeong YH. Effect of Ticagrelor on Left Ventricular Remodeling in Patients With ST-Segment Elevation Myocardial Infarction (HEALING-AMI). JACC Cardiovasc Interv 2021; 13:2220-2234. [PMID: 33032710 DOI: 10.1016/j.jcin.2020.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of ticagrelor versus clopidogrel on left ventricular (LV) remodeling after reperfusion of ST-segment elevation myocardial infarction (STEMI) in humans. BACKGROUND Animal studies have demonstrated that ticagrelor compared with clopidogrel better protects myocardium against reperfusion injury and improves remodeling after myocardial infarction. METHODS In this investigator-initiated, randomized, open-label, assessor-blinded trial performed at 10 centers in Korea, patients were enrolled if they had naive STEMI successfully treated with primary percutaneous coronary intervention (PCI) and at least 6-month planned duration of dual-antiplatelet treatment. The coprimary endpoints were LV remodeling index (LVRI) (a relative change of LV end-diastolic volume) measured on 3-dimensional echocardiography and N-terminal pro-B-type natriuretic peptide level at 6 months. RESULTS Among initially enrolled patients with STEMI (n = 336), 139 in each group completed the study. LVRI at 6 months was numerically lower with ticagrelor versus clopidogrel (0.6 ± 18.6% vs. 4.5 ± 16.5%; p = 0.095). Ticagrelor significantly reduced the 6-month level of N-terminal pro-B-type natriuretic peptide (173 ± 141 pg/ml vs. 289 ± 585 pg/ml; p = 0.028). These differences were prominent in patients with pre-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade 0. By multivariate analysis, ticagrelor versus clopidogrel reduced the risk for positive LV remodeling (LVRI >0%) (odds ratio: 0.56; 95% confidence interval: 0.33 to 0.95; p = 0.030). The LV end-diastolic volume index remained unchanged during ticagrelor treatment (from 54.7 ± 12.2 to 54.2 ± 12.2 ml/m2; p = 0.629), but this value increased over time during clopidogrel treatment (from 54.6 ± 11.3 to 56.4 ± 13.9 ml/m2; p = 0.056) (difference -2.3 ml/m2; 95% confidence interval: -4.8 to 0.2 ml/m2; p = 0.073). Ticagrelor reduced LV end-systolic volume index (from 27.0 ± 8.5 to 24.7 ± 8.4 ml/m2; p < 0.001), whereas no reduction was seen with clopidogrel (from 26.2 ± 8.9 to 25.6 ± 11.0 ml/m2; p = 0.366) (difference -1.8 ml/m2; 95% confidence interval: -3.5 to -0.1 ml/m2; p = 0.040). CONCLUSIONS Ticagrelor was superior to clopidogrel for LV remodeling after reperfusion of STEMI with primary PCI. (High Platelet Inhibition With Ticagrelor to Improve Left Ventricular Remodeling in Patients With ST Segment Elevation Myocardial Infarction [HEALING-AMI]; NCT02224534).
Collapse
Affiliation(s)
- Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jin Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jae-Hwan Lee
- Department of Cardiology, Chungnam National University Hospital, Daejeon, South Korea
| | - Jae-Hyeong Park
- Department of Cardiology, Chungnam National University Hospital, Daejeon, South Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan Medical Center, Ulsan Hospital, Ulsan, South Korea
| | - Ju Hyeon Oh
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Woojung Chun
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Sang Yeub Lee
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Jeong Su Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Weon Kim
- Cardiovascular Department of Internal Medicine, Kyung Hee University Hospital, Seoul, South Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong Heon Yang
- Department of Cardiology, Kyungpook National University Hospital, Daegu, South Korea
| | - Young-Joon Hong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Mark Y Chan
- Singapore National University Heart Center, Singapore National University Hospital, Singapore, Singapore
| | - Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Hyun-Woong Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Si Wan Choi
- Department of Cardiology, Chungnam National University Hospital, Daejeon, South Korea.
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea.
| |
Collapse
|
2
|
Park Y, Choi SW, Oh JH, Shin ES, Lee SY, Kim J, Kim W, Suh JW, Yang DH, Hong YJ, Chan MY, Koh JS, Hwang JY, Park JH, Jeong YH. Rationale and Design of the High Platelet Inhibition with Ticagrelor to Improve Left Ventricular Remodeling in Patients with ST-Segment Elevation Myocardial Infarction (HEALING-AMI) Trial. Korean Circ J 2019; 49:586-599. [PMID: 31074220 PMCID: PMC6597457 DOI: 10.4070/kcj.2018.0415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/05/2019] [Accepted: 02/20/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Impaired recovery from left ventricular (LV) dysfunction is a major prognostic factor after myocardial infarction (MI). Because P2Y₁₂ receptor blockade inhibits myocardial injury, ticagrelor with off-target properties may have myocardial protection over clopidogrel. In animal models, ticagrelor vs. clopidogrel protects myocardium against reperfusion injury and improves remodeling after MI. We aimed to investigate the effect of ticagrelor on sequential myocardial remodeling process after MI. METHODS High platelet inhibition with ticagrelor to improve LV remodeling in patients with ST-segment elevation MI (HEALING-AMI) is an investigator-initiated, randomized, open-label, assessor-blinded, multi-center trial done at 10 sites in Korea. Patients will be enrolled if they have ST-segment elevation MI (STEMI) treated with primary percutaneous coronary intervention and a planned duration of dual antiplatelet treatment of at least 6 months. Screened patients will be randomly assigned (1:1) using an internet-based randomization with a computer-generated blocking with stratification across study sites to either ticagrelor or clopidogrel treatment. The co-primary primary endpoints are LV remodeling index with three-dimensional echocardiography and the level of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) at 6 months representing post-MI remodeling processes. Changes of LV end-systolic/diastolic volume indices and LV ejection fraction between baseline and 6-month follow-up will be also evaluated. Analysis is per protocol. CONCLUSIONS HEALING-AMI is testing the effect of ticagrelor in reducing adverse LV remodeling following STEMI. Our trial would show the benefit of ticagrelor vs. clopidogrel related to the recovery of post-MI LV dysfunction beyond potent platelet inhibition. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02224534.
Collapse
Affiliation(s)
- Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Si Wan Choi
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ju Hyeon Oh
- Department of Internal Medicine, Changwon Samsung Medical Center, Changwon, Korea
| | - Eun Seok Shin
- Division of Cardiology, Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Sang Yeub Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Jeongsu Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Jeong Won Suh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Heon Yang
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Young Joon Hong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Mark Y Chan
- Department of Cardiology, Singapore National University Heart Centre, Singapore
| | - Jin Sin Koh
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin Yong Hwang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jae Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Young Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea.
| | | |
Collapse
|