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Patrono C. Low-dose aspirin for the prevention of atherosclerotic cardiovascular disease. Eur Heart J 2024:ehae324. [PMID: 38839268 DOI: 10.1093/eurheartj/ehae324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/22/2024] [Accepted: 05/11/2024] [Indexed: 06/07/2024] Open
Abstract
During the past 30 years, several developments have occurred in the antiplatelet field, including the role of aspirin in primary prevention of atherosclerotic cardiovascular disease. There have been several attempts to develop antiplatelet drugs more effective and safer than aspirin and a shift in emphasis from efficacy to safety, advocating aspirin-free antiplatelet regimens after percutaneous coronary intervention. Evidence supporting a chemopreventive effect of low-dose aspirin against colorectal (and other digestive tract) cancer has also strengthened. The aim of this article is to revisit the role of aspirin in the prevention of atherothrombosis across the cardiovascular risk continuum, in view of developments in the antiplatelet field. The review will offer a clinical perspective on aspirin's mechanism of action, pharmacokinetics, and pharmacodynamics. This will be followed by a detailed discussion of its clinical efficacy and safety.
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Affiliation(s)
- Carlo Patrono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
- Center of Excellence on Ageing, University of Chieti, Via Luigi Polacchi 11, 66100 Chieti, Italy
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Wang Q, Li H, Wu T, Yu B, Cong H, Shen Y. Nanodrugs based on co-delivery strategies to combat cisplatin resistance. J Control Release 2024; 370:14-42. [PMID: 38615892 DOI: 10.1016/j.jconrel.2024.04.020] [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: 12/30/2023] [Revised: 03/24/2024] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
Cisplatin (CDDP), as a broad-spectrum anticancer drug, is able to bind to DNA and inhibit cell division. Despite the widespread use of cisplatin since its discovery, cisplatin resistance developed during prolonged chemotherapy, similar to other small molecule chemotherapeutic agents, severely limits its clinical application. Cisplatin resistance in cancer cells is mainly caused by three reasons: DNA repair, decreased cisplatin uptake/increased efflux, and cisplatin inactivation. In earlier combination therapies, the emergence of multidrug resistance (MDR) in cancer cells prevented the achievement of the desired therapeutic effect even with the accurate combination of two chemotherapeutic drugs. Therefore, combination therapy using nanocarriers for co-delivery of drugs is considered to be ideal for alleviating cisplatin resistance and reducing cisplatin-related toxicity in cancer cells. This article provides an overview of the design of cisplatin nano-drugs used to combat cancer cell resistance, elucidates the mechanisms of action of cisplatin and the pathways through which cancer cells develop resistance, and finally discusses the design of drugs and related carriers that can synergistically reduce cancer resistance when combined with cisplatin.
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Affiliation(s)
- Qiubo Wang
- College of Chemistry and Chemical Engineering, College of Materials Science and Engineering, Institute of Biomedical Materials and Engineering, Qingdao University, Qingdao 266071, China
| | - Hui Li
- College of Chemistry and Chemical Engineering, College of Materials Science and Engineering, Institute of Biomedical Materials and Engineering, Qingdao University, Qingdao 266071, China
| | - Taixia Wu
- College of Chemistry and Chemical Engineering, College of Materials Science and Engineering, Institute of Biomedical Materials and Engineering, Qingdao University, Qingdao 266071, China
| | - Bing Yu
- College of Chemistry and Chemical Engineering, College of Materials Science and Engineering, Institute of Biomedical Materials and Engineering, Qingdao University, Qingdao 266071, China; State Key Laboratory of Bio-Fibers and Eco-Textiles, Qingdao University, Qingdao 266071, China.
| | - Hailin Cong
- College of Chemistry and Chemical Engineering, College of Materials Science and Engineering, Institute of Biomedical Materials and Engineering, Qingdao University, Qingdao 266071, China; State Key Laboratory of Bio-Fibers and Eco-Textiles, Qingdao University, Qingdao 266071, China; School of Materials Science and Engineering, Shandong University of Technology, Zibo 255000, China.
| | - Youqing Shen
- College of Chemistry and Chemical Engineering, College of Materials Science and Engineering, Institute of Biomedical Materials and Engineering, Qingdao University, Qingdao 266071, China; Key Laboratory of Biomass Chemical Engineering of Ministry of Education, Center for Bio-nanoengineering, and Department of Chemical and Biological Engineering, Zhejiang University, Hangzhou, Zhejiang 310027, China
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3
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Li Y, Li J, Wang B, Jing Q, Zeng Y, Hou A, Wang Z, Liu A, Zhang J, Zhang Y, Zhang P, Jiang D, Liu B, Fan J, Zhang J, Li L, Su G, Yang M, Jiang W, Qu P, Zeng H, Li L, Qiu M, Ru L, Chen S, Zhou Y, Qiao S, Stone GW, Angiolillo DJ, Han Y. Extended Clopidogrel Monotherapy vs DAPT in Patients With Acute Coronary Syndromes at High Ischemic and Bleeding Risk: The OPT-BIRISK Randomized Clinical Trial. JAMA Cardiol 2024; 9:523-531. [PMID: 38630489 PMCID: PMC11024736 DOI: 10.1001/jamacardio.2024.0534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/02/2024] [Indexed: 04/20/2024]
Abstract
Importance Purinergic receptor P2Y12 (P2Y12) inhibitor monotherapy after a certain period of dual antiplatelet therapy (DAPT) may be an attractive option of maintenance antiplatelet treatment for patients undergoing percutaneous coronary intervention (PCI) who are at both high bleeding and ischemic risk (birisk). Objective To determine if extended P2Y12 inhibitor monotherapy with clopidogrel is superior to ongoing DAPT with aspirin and clopidogrel after 9 to 12 months of DAPT after PCI in birisk patients with acute coronary syndromes (ACS). Design, Setting, and Participants This was a multicenter, double-blind, placebo-controlled, randomized clinical trial including birisk patients with ACS who had completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months at 101 China centers between February 2018 and December 2020. Study data were analyzed from April 2023 to May 2023. Interventions Patients were randomized either to clopidogrel plus placebo or clopidogrel plus aspirin for an additional 9 months. Main Outcomes and Measures The primary end point was Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding 9 months after randomization. The key secondary end point was major adverse cardiac and cerebral events (MACCE; the composite of all-cause death, myocardial infarction, stroke or clinically driven revascularization). The primary end point was tested for superiority, and the MACCE end point was tested for sequential noninferiority and superiority. Results A total of 7758 patients (mean [SD] age, 64.8 [9.0] years; 4575 male [59.0%]) were included in this study. The primary end point of BARC types 2, 3, or 5 bleeding occurred in 95 of 3873 patients (2.5%) assigned to clopidogrel plus placebo and 127 of 3885 patients (3.3%) assigned to clopidogrel plus aspirin (hazard ratio [HR], 0.75; 95% CI, 0.57-0.97; difference, -0.8%; 95% CI, -1.6% to -0.1%; P = .03). The incidence of MACCE was 2.6% (101 of 3873 patients) in the clopidogrel plus placebo group and 3.5% (136 of 3885 patients) in the clopidogrel plus aspirin group (HR, 0.74; 95% CI, 0.57-0.96; difference, -0.9%; 95% CI, -1.7% to -0.1%; P < .001 for noninferiority; P = .02 for superiority). Conclusions and Relevance Among birisk patients with ACS who completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months before randomization, an extended 9-month clopidogrel monotherapy regimen was superior to continuing DAPT with clopidogrel in reducing clinically relevant bleeding without increasing ischemic events. Trial Registration ClinicalTrials.gov Identifier: NCT03431142.
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Affiliation(s)
- Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Wang
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanmin Jing
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Yujie Zeng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aijie Hou
- The People’s Hospital of Liaoning Province, Shenyang, China
| | | | - Aijun Liu
- Benxi Central Hospital, Benxi, China
| | | | | | - Ping Zhang
- Beijing Tsinghua Changgung Hospital, Beijing, China
| | | | - Bin Liu
- The Second Hospital of Jilin University, Changchun, China
| | | | - Jun Zhang
- Cangzhou Central Hospital, Cangzhou, China
| | - Li Li
- Guangzhou Red Cross Hospital, Guangzhou, China
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical University, Ji’nan, China
| | - Ming Yang
- Yingkou Central Hospital, Yingkou, China
| | - Weihong Jiang
- The Third Xiangya Hospital of Central South University, Changsha, China
| | - Peng Qu
- The Second Hospital of Dalian Medical University, Dalian, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Lu Li
- The Second Affiliated Hospital of Shenyang Medical College, Shenyang, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Leisheng Ru
- Bethune International Peace Hospital, Shijiazhuang, China
| | | | - Yujie Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shubin Qiao
- Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
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Krucoff M, Spirito A, Baber U, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Ticagrelor with or without aspirin following percutaneous coronary intervention in high-risk patients with concomitant peripheral artery disease: A subgroup analysis of the TWILIGHT randomized clinical trial. Am Heart J 2024; 272:11-22. [PMID: 38458371 DOI: 10.1016/j.ahj.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The optimal antiplatelet regimen after percutaneous coronary intervention (PCI) in patients with peripheral artery disease (PAD) is still debated. This analysis aimed to compare the effect of ticagrelor monotherapy versus ticagrelor plus aspirin in patients with PAD undergoing PCI. METHODS In the TWILIGHT trial, patients at high ischemic or bleeding risk that underwent PCI were randomized after 3 months of dual antiplatelet therapy (DAPT) to aspirin or matching placebo in addition to open-label ticagrelor for 12 additional months. In this post-hoc analysis, patient cohorts were examined according to the presence or absence of PAD. The primary endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke. Endpoints were assessed at 12 months after randomization. RESULTS Among 7,119 patients, 489 (7%) had PAD and were older, more likely to have comorbidities, and multivessel disease. PAD patients had more bleeding or ischemic complications than no-PAD patients. Ticagrelor monotherapy compared to ticagrelor plus aspirin was associated with less BARC 2, 3, or 5 bleeding in PAD (4.6% vs 8.7%; HR 0.52; 95%CI 0.25-1.07) and no-PAD patients (4.0% vs 7.0%; HR 0.56; 95%CI 0.45-0.69; interaction P-value .830) and a similar risk of death, MI, or stroke in these 2 groups (interaction P-value .446). CONCLUSIONS Despite their higher ischemic and bleeding risk, patients with PAD undergoing PCI derived a consistent benefit from ticagrelor monotherapy after 3 months of DAPT in terms of bleeding reduction without any relevant increase in ischemic events. CLINICAL TRIAL REGISTRY INFORMATION:: https://www. CLINICALTRIALS gov/study/NCT02270242.
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Affiliation(s)
- Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY; St. Francis Hospital, Roslyn, Roslyn, NY
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang 110016, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Finocchiaro S, Capodanno D. Rethinking Aspirin: Ditching the Daily "Pill"ar of Tradition. JACC Cardiovasc Interv 2024; 17:1246-1251. [PMID: 38811106 DOI: 10.1016/j.jcin.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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Cao D, Vranckx P, Valgimigli M, Sartori S, Angiolillo DJ, Bangalore S, Bhatt DL, Feng Y, Ge J, Hermiller J, Makkar RR, Neumann FJ, Saito S, Picon H, Toelg R, Maksoud A, Chehab BM, Choi JW, Campo G, De la Torre Hernandez JM, Krucoff MW, Kunadian V, Sardella G, Spirito A, Thiele H, Varenne O, Vogel B, Zhou Y, Windecker S, Mehran R. One- versus three-month dual antiplatelet therapy in high bleeding risk patients undergoing percutaneous coronary intervention for non-ST-segment elevation acute coronary syndromes. EUROINTERVENTION 2024; 20:e630-e642. [PMID: 38776146 PMCID: PMC11100501 DOI: 10.4244/eij-d-23-00658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/12/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND A short dual antiplatelet therapy (DAPT) duration has been proposed for patients at high bleeding risk (HBR) undergoing drug-eluting coronary stent (DES) implantation. Whether this strategy is safe and effective after a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. AIMS We aimed to compare the impact of 1-month versus 3-month DAPT on clinical outcomes after DES implantation among HBR patients with or without NSTE-ACS. METHODS This is a prespecified analysis from the XIENCE Short DAPT programme involving three prospective, international, single-arm studies evaluating the safety and efficacy of 1-month (XIENCE 28 USA and Global) or 3-month (XIENCE 90) DAPT among HBR patients after implantation of a cobalt-chromium everolimus-eluting stent. Ischaemic and bleeding outcomes associated with 1- versus 3-month DAPT were assessed according to clinical presentation using propensity score stratification. RESULTS Of 3,364 HBR patients (1,392 on 1-month DAPT and 1,972 on 3-month DAPT), 1,164 (34.6%) underwent DES implantation for NSTE-ACS. At 12 months, the risk of the primary endpoint of death or myocardial infarction was similar between 1- and 3-month DAPT in patients with (hazard ratio [HR] 1.09, 95% confidence interval [CI]: 0.71-1.65) and without NSTE-ACS (HR 0.88, 95% CI: 0.63-1.23; p-interaction=0.34). The key secondary endpoint of Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding was consistently reduced in both NSTE-ACS (HR 0.57, 95% CI: 0.37-0.88) and stable patients (HR 0.84, 95% CI: 0.61-1.15; p-interaction=0.15) with 1-month DAPT. CONCLUSIONS Among HBR patients undergoing implantation of an everolimus-eluting stent, 1-month, compared to 3-month DAPT, was associated with similar ischaemic risk and reduced bleeding at 1 year, irrespective of clinical presentation.
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Affiliation(s)
- Davide Cao
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Pascal Vranckx
- Heart Centre Hasselt, Hasselt, Belgium and University of Hasselt, Hasselt, Belgium
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Bern University Hospital, Bern, Switzerland
| | - Samantha Sartori
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yihan Feng
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Junbo Ge
- Zhongshan Hospital Fudan University, Shanghai, China
| | - James Hermiller
- St Vincent's Medical Center of Indiana, Indianapolis, IN, USA
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | - Ralph Toelg
- Segeberger Kliniken GmbH, Herzzentrum, Bad Segeberg, Germany
| | - Aziz Maksoud
- Kansas Heart Hospital, Wichita, KS, USA and University of Kansas School of Medicine, Wichita, KS, USA
| | | | - James W Choi
- Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | - Gianluca Campo
- Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | | | - Mitchell W Krucoff
- Duke University Medical Center, Durham, NC, USA and Duke Clinical Research Institute, Durham, NC, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Alessandro Spirito
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany and Leipzig Heart Institute, Leipzig, Germany
| | | | - Birgit Vogel
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Lee SY, Cho JY, Gorog DA, Angiolillo DJ, Yun KH, Ahn JH, Koh JS, Park Y, Hwang SJ, Hwang JY, Kim JW, Jang Y, Jeong YH. Inflammation and platelet reactivity during adjunctive colchicine versus aspirin in patients with acute coronary syndrome treated with potent P2Y12 inhibitor. Front Med (Lausanne) 2024; 11:1349577. [PMID: 38841588 PMCID: PMC11151890 DOI: 10.3389/fmed.2024.1349577] [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: 12/04/2023] [Accepted: 03/28/2024] [Indexed: 06/07/2024] Open
Abstract
Background In patients undergoing percutaneous coronary intervention (PCI), the use of anti-inflammatory therapy with colchicine is associated with a reduction of recurrent ischemic events. The mechanisms of such findings are not fully elucidated. Objectives To investigate the effects of colchicine versus aspirin on inflammation and platelet reactivity in patients with acute coronary syndrome (ACS) undergoing PCI. Methods This observational study compared laboratory measurements in ACS patients receiving single antiplatelet therapy with ticagrelor or prasugrel plus colchicine (MACT) (n = 185) versus conventional dual-antiplatelet therapy (DAPT) with aspirin plus ticagrelor or prasugrel (n = 497). The primary outcome was the frequency of high residual inflammation, defined as high-sensitivity C-reactive protein (hs-CRP) ≥2 mg/L at 1 month post-PCI. Multiple sensitivity analyses were performed for the primary outcome, including multivariable adjustment, propensity-score matching, and inverse-probability weighted methods. Results One month after PCI, patients treated with MACT had significantly lower levels of hs-CRP compared to those treated with DAPT (0.6 [0.4-1.2] vs. 0.9 [0.6-2.3] mg/L, p < 0.001). The frequency of high residual inflammation was also lower in the MACT group (10.8% vs. 27.2%, p < 0.001) (odds ratio [95% confidence interval] = 0.33 [0.20-0.54], p < 0.001). This effect was consistent across sensitivity analyses. There was no difference in platelet reactivity between MACT and DAPT (49.6 ± 49.0 vs. 51.5 ± 66.4 P2Y12 reaction unit [PRU] measured by VerifyNow, p = 0.776). Conclusion In ACS patients undergoing PCI, MACT was associated with a lower rate of high residual inflammation without increasing platelet reactivity compared to conventional DAPT. Clinical trial registration NCT04949516 for MACT pilot trial and NCT04650529 for Gyeongsang National University Hospital registry.
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Affiliation(s)
- Seung-Yul Lee
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Republic of Korea
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jae Young Cho
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Diana A. Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Kyeong Ho Yun
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Division of Cardiology, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Division of Cardiology, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Division of Cardiology, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin Won Kim
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Yangsoo Jang
- Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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8
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Spirito A, Krishnan SL, Capodanno D, Angiolillo DJ, Mehran R. Antiplatelet De-Escalation Strategies in Patients Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2024; 17:e013263. [PMID: 38626078 DOI: 10.1161/circinterventions.123.013263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
Dual antiplatelet therapy-the combination of aspirin and a P2Y12 inhibitor-remains the standard antiplatelet regimen recommended to prevent ischemic complications immediately after percutaneous coronary intervention. Nonetheless, recent advances in stent technologies, percutaneous coronary intervention techniques, adjunctive pharmacotherapy for secondary prevention, and the rising awareness of the prognostic impact of bleeding, which are inevitably associated with dual antiplatelet therapy, led to the investigation of alternative antiplatelet regimens related to fewer bleeding and a preserved ischemic protection. Thrombotic complications occur mostly in the first months after percutaneous coronary intervention, while the risk of bleeding remains stable over time; this observation laid the foundation of the concept of antiplatelet de-escalation, consisting of a more intense antiplatelet regimen early after percutaneous coronary intervention, followed by a less potent antiplatelet therapy thereafter. According to new definitions proposed by the Academic Research Consortium, de-escalation can be achieved by discontinuation of 1 antiplatelet agent, switching from a potent P2Y12 inhibitor to clopidogrel, or by reducing the dose of antiplatelet agents. This review discusses the rationale and the evidence supporting antiplatelet de-escalation, provides practical guidance to use these new regimens, and gives insights into future developments in the field.
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Affiliation(s)
- Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (A.S., S.L.K., R.M.)
| | - Sriya L Krishnan
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (A.S., S.L.K., R.M.)
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," Catania, Italy (D.C.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (A.S., S.L.K., R.M.)
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Guo Y, Mao T, Fang Y, Wang H, Yu J, Zhu Y, Shen S, Zhou M, Li H, Hu Q. Comprehensive insights into potential roles of purinergic P2 receptors on diseases: Signaling pathways involved and potential therapeutics. J Adv Res 2024:S2090-1232(24)00123-1. [PMID: 38565403 DOI: 10.1016/j.jare.2024.03.027] [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: 01/17/2024] [Revised: 03/03/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Purinergic P2 receptors, which can be divided into ionotropic P2X receptors and metabotropic P2Y receptors, mediate cellular signal transduction of purine or pyrimidine nucleoside triphosphates and diphosphate. Based on the wide expression of purinergic P2 receptors in tissues and organs, their significance in homeostatic maintenance, metabolism, nociceptive transmission, and other physiological processes is becoming increasingly evident, suggesting that targeting purinergic P2 receptors to regulate biological functions and signal transmission holds significant promise for disease treatment. AIM OF REVIEW This review highlights the detailed mechanisms by which purinergic P2 receptors engage in physiological and pathological progress, as well as providing prospective strategies for discovering clinical drug candidates. KEY SCIENTIFIC CONCEPTS OF REVIEW The purinergic P2 receptors regulate complex signaling and molecular mechanisms in nervous system, digestive system, immune system and as a result, controlling physical health states and disease progression. There has been a significant rise in research and development focused on purinergic P2 receptors, contributing to an increased number of drug candidates in clinical trials. A few influential pioneers have laid the foundation for advancements in the evaluation, development, and of novel purinergic P2 receptors modulators, including agonists, antagonists, pharmaceutical compositions and combination strategies, despite the different scaffolds of these drug candidates. These advancements hold great potential for improving therapeutic outcomes by specifically targeting purinergic P2 receptors.
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Affiliation(s)
- Yanshuo Guo
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Tianqi Mao
- College of Pharmaceutical Sciences, Soochow University, Suzhou 215006, China
| | - Yafei Fang
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Hui Wang
- College of Pharmaceutical Sciences, Soochow University, Suzhou 215006, China
| | - Jiayue Yu
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Yifan Zhu
- College of Pharmaceutical Sciences, Soochow University, Suzhou 215006, China
| | - Shige Shen
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China
| | - Mengze Zhou
- School of Pharmacy, China Pharmaceutical University, Nanjing 211198, China.
| | - Huanqiu Li
- College of Pharmaceutical Sciences, Soochow University, Suzhou 215006, China.
| | - Qinghua Hu
- School of Life Science and Technology, China Pharmaceutical University, Nanjing 211198, China.
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10
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Min PK, Kang TS, Cho YH, Cheong SS, Kim BK, Kwon SW, Park WJ, Lee JH, Kim W, Lee WS, Yoon YW, Lee BK, Kwon HM, Hong BK. P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy After Deployment of a Drug-Eluting Stent: The SHARE Randomized Clinical Trial. JAMA Netw Open 2024; 7:e240877. [PMID: 38451525 PMCID: PMC10921250 DOI: 10.1001/jamanetworkopen.2024.0877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
Importance P2Y12 inhibitor monotherapy after dual antiplatelet therapy (DAPT; a P2Y12 inhibitor plus aspirin) for a brief duration has recently emerged as an attractive alternative for patients undergoing percutaneous coronary intervention (PCI) with a drug-eluting stent. Objective To investigate whether P2Y12 inhibitor monotherapy after 3 months of DAPT was noninferior to 12 months of DAPT following PCI with a drug-eluting stent. Design, Setting, and Participants The Short-Term Dual Antiplatelet Therapy After Deployment of Bioabsorbable Polymer Everolimus-Eluting Stent (SHARE) open-label, noninferiority randomized clinical trial was conducted from December 15, 2017, through December 14, 2020. Final 1-year clinical follow-up was completed in January 2022. This study was a multicenter trial that was conducted at 20 hospitals in South Korea. Patients who underwent successful PCI with bioabsorbable polymer everolimus-eluting stents were enrolled. Interventions Patients were randomly assigned to receive P2Y12 inhibitor monotherapy after 3 months of DAPT (n = 694) or 12 months of DAPT (n = 693). Main Outcomes and Measures The primary outcome was a net adverse clinical event, a composite of major bleeding (based on Bleeding Academic Research Consortium type 3 or type 5 bleeding) and major adverse cardiac and cerebrovascular events (cardiac death, myocardial infarction, stent thrombosis, stroke, or ischemia-driven target lesion revascularization) between 3 and 12 months after the index PCI. The major secondary outcomes were major adverse cardiac and cerebrovascular events and major bleeding. The noninferiority margin was 3.0%. Results Of the total 1452 eligible patients, 65 patients were excluded before the 3-month follow-up, and 1387 patients (mean [SD] age, 63.0 [10.7] years; 1055 men [76.1%]) were assigned to P2Y12 inhibitor monotherapy (n = 694) or DAPT (n = 693). Between 3 and 12 months of follow-up, the primary outcome (using Kaplan-Meier estimates) occurred in 9 patients (1.7%) in the P2Y12 inhibitor monotherapy group and in 16 patients (2.6%) in the DAPT group (absolute difference, -0.93 [1-sided 95% CI, -2.64 to 0.77] percentage points; P < .001 for noninferiority). For the major secondary outcomes (using Kaplan-Meier estimates), major adverse cardiac and cerebrovascular events occurred in 8 patients (1.5%) in the P2Y12 inhibitor monotherapy group and in 12 patients (2.0%) in the DAPT group (absolute difference, -0.49 [95% CI, -2.07 to 1.09] percentage points; P = .54). Major bleeding occurred in 1 patient (0.2%) in the P2Y12 inhibitor monotherapy group and in 5 patients (0.8%) in the DAPT group (absolute difference, -0.60 [95% CI, -1.33 to 0.12] percentage points; P = .10). Conclusions and Relevance In patients with coronary artery disease undergoing PCI with the latest generation of drug-eluting stents, P2Y12 inhibitor monotherapy after 3-month DAPT was not inferior to 12-month DAPT for net adverse clinical events. Considering the study population and lower-than-expected event rates, further research is required in other populations. Trial Registration ClinicalTrials.gov Identifier: NCT03447379.
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Affiliation(s)
- Pil-Ki Min
- Cardiology Division, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Soo Kang
- Division of Cardiology, Dankook University Hospital, Cheonan, Republic of Korea
| | - Yun-Hyeong Cho
- Division of Cardiology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Sang-Sig Cheong
- Department of Cardiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Woo Kwon
- Division of Cardiology, Inha University Hospital, Incheon, Republic of Korea
| | - Woo Jung Park
- Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jung-Hee Lee
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Wonho Kim
- Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Wang-Soo Lee
- Heart Research Institute, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Young Won Yoon
- Cardiology Division, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byoung Kwon Lee
- Cardiology Division, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyuck Moon Kwon
- Cardiology Division, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bum-Kee Hong
- Cardiology Division, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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11
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Gragnano F, Capolongo A, Calabrò P. P2Y 12 Inhibitor or Aspirin Monotherapy in Patients with Coronary Artery Disease: is it Time for a Paradigm Shift? Curr Vasc Pharmacol 2024; 22:1-4. [PMID: 38018206 DOI: 10.2174/0115701611269735231106110250] [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: 07/23/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
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12
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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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13
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Gragnano F, Capolongo A, Micari A, Costa F, Garcia-Ruiz V, De Sio V, Terracciano F, Cesaro A, Moscarella E, Coletta S, Raucci P, Fimiani F, De Luca L, Gargiulo G, Andò G, Calabrò P. Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. J Clin Med 2023; 13:98. [PMID: 38202105 PMCID: PMC10780105 DOI: 10.3390/jcm13010098] [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: 11/08/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
The antithrombotic management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) poses numerous challenges. Triple antithrombotic therapy (TAT), which combines dual antiplatelet therapy (DAPT) with oral anticoagulation (OAC), provides anti-ischemic protection but increases the risk of bleeding. Therefore, TAT is generally limited to a short phase (1 week) after PCI, followed by aspirin withdrawal and continuation of 6-12 months of dual antithrombotic therapy (DAT), comprising OAC plus clopidogrel, followed by OAC alone. This pharmacological approach has been shown to mitigate bleeding risk while preserving adequate anti-ischemic efficacy. However, the decision-making process remains complex in elderly patients and those with co-morbidities, significantly influencing ischemic and bleeding risk. In this review, we discuss the available evidence in this area from randomized clinical trials and meta-analyses for post-procedural antithrombotic therapies in patients with non-valvular AF undergoing PCI.
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | | | - Vincenzo De Sio
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabrizia Terracciano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Silvio Coletta
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Pasquale Raucci
- Division of Health Technology Assessment, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, Azienda Ospedaliera di Rilievo Nazionale Dei Colli, “Vincenzo Monaldi”, CCMR Regione Campania, 80138 Naples, Italy;
| | - Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, 00152 Roma, Italy;
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
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14
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De Luca L, Gragnano F, Calabrò P, Huber K. Balancing Benefits and Risks of Oral Antiplatelet Strategies in patients With Coronary Artery Diseases: An Evolving Issue. Curr Probl Cardiol 2023; 48:102025. [PMID: 37553063 DOI: 10.1016/j.cpcardiol.2023.102025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Identifying the most appropriate antiplatelet therapy for each patient to prevent ischemic events while minimizing the risk of bleeding is an integral part of the short- and long-term management of patients with coronary artery disease (CAD). This review aims to summarize the available evidence on the contemporary use of P2Y12 inhibitors in CAD patients, focusing on strategies aimed at providing adequate ischemic protection while preventing bleeding risk through dual antiplatelet therapy (DAPT) modulation. Randomized trials and observational studies have been reviewed to determine the most appropriate antiplatelet treatment for CAD patients with different risk profiles. Both ischemic and bleeding events have a significant prognostic impact and should be carefully considered in clinical decision-making. Current guidelines recommend the use of third-generation PY2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel, as a part of DAPT, in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Newer P2Y12 inhibitors have a more rapid onset of action and less interindividual variability in platelet inhibition than clopidogrel but are associated with an increased risk of bleeding that may limit their benefit. Importantly, the anti-ischemic benefit of ticagrelor and prasugrel is mainly observed in the first weeks after ACS, whereas clopidogrel seems to provide the best balance between ischemic protection and bleeding as long-term maintenance therapy. These concepts support DAPT modulation after the acute phase, by de-escalating from full-dose to low-dose newer P2Y12 inhibitors, by switching to clopidogrel, or by early withdrawing aspirin to maximize both the efficacy and safety of antiplatelet therapy in patients with CAD.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, and Sigmund Freud University, Medical Faculty, Vienna, Austria
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Yang S, Kang J, Park KW, Hur SH, Lee NH, Hwang D, Yang HM, Ahn HS, Cha KS, Jo SH, Ryu JK, Suh IW, Choi HH, Woo SI, Han JK, Shin ES, Koo BK, Kim HS. Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic, and Bleeding Risks. J Am Coll Cardiol 2023; 82:1565-1578. [PMID: 37821166 DOI: 10.1016/j.jacc.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Clopidogrel was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI). OBJECTIVES The purpose of this study was to evaluate the benefits of clopidogrel across high-risk subgroups METHODS: This was a post hoc analysis of the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy) trial that randomly assigned patients who were event free for 6 to 18 months post-PCI on dual antiplatelet therapy (DAPT) to clopidogrel or aspirin monotherapy. Two clinical risk scores were used for risk stratification: the DAPT score and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) (the sum of age ≥75 years, diabetes, hypertension, current smoking, peripheral artery disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction). The primary composite endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission because of acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type ≥3) at 2 years after randomization. RESULTS Among 5,403 patients, clopidogrel monotherapy showed a lower rate of the primary composite endpoint than aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90). The benefit of clopidogrel over aspirin was consistent regardless of TRS 2°P (high TRS 2°P [≥3] group: HR: 0.65 [95% CI: 0.44-0.96]; and low TRS 2°P [<3] group: HR: 0.77 [95% CI: 0.60-0.99]) (P for interaction = 0.454) and regardless of DAPT score (high DAPT score [≥2] group: HR: 0.68 [95% CI: 0.46-1.00]; and low DAPT score [<2] group: HR: 0.75 [95% CI: 0.59-0.96]) (P for interaction = 0.662). The association was similar for the individual outcomes. CONCLUSIONS The beneficial effect of clopidogrel over aspirin monotherapy was consistent regardless of clinical risk or relative ischemic and bleeding risks compared with aspirin monotherapy. (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis- EXtended Antiplatelet Monotherapy [HOST-EXAM]; NCT02044250).
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Affiliation(s)
- Seokhun Yang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Seung-Ho Hur
- Keimyung University Dongsan Hospital, Daegu, Republic of Korea.
| | - Nam Ho Lee
- Kangnam Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Suk Ahn
- Uijeongbu St Mary's Hospital, Uijeongbu, Republic of Korea
| | - Kwang Soo Cha
- Pusan National University Hospital, Busan, Republic of Korea
| | - Sang-Ho Jo
- Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jae Kean Ryu
- Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Il-Woo Suh
- Anyang SAM Medical Center, Anyang, Republic of Korea
| | - Hyun-Hee Choi
- Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Seong-Ill Woo
- Inha University Hospital, Inha University, Incheon, Republic of Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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16
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Capodanno D, Angiolillo DJ. Personalised antiplatelet therapies for coronary artery disease: what the future holds. Eur Heart J 2023; 44:3059-3072. [PMID: 37345589 DOI: 10.1093/eurheartj/ehad362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/07/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023] Open
Abstract
Coronary artery disease (CAD) is one of the leading causes of death globally, and antiplatelet therapy is crucial for both its prevention and treatment. Antiplatelet drugs such as aspirin and P2Y12 inhibitors are commonly used to reduce the risk of thrombotic events, including myocardial infarction, stroke, and stent thrombosis. However, the benefits associated with the use of antiplatelet drugs also come with a risk of bleeding complications. The ever-growing understanding of the poor prognostic implications associated with bleeding has set the foundations for defining strategies that can mitigate such safety concern without any trade-off in antithrombotic protection. To this extent, personalised antiplatelet therapy has emerged as a paradigm that optimizes the balance between safety and efficacy by customizing treatment to the individual patient's needs and risk profile. Accurate risk stratification for both bleeding and thrombosis can aid in selecting the optimal antiplatelet therapy and prevent serious and life-threatening outcomes. Risk stratification has traditionally included clinical and demographic characteristics and has expanded to incorporate angiographic features and laboratory findings. The availability of bedside platelet function testing as well as rapid genotyping assays has also allowed for a more individualized selection of antiplatelet therapy. This review provides a comprehensive overview of the current state of the art and future trends in personalised antiplatelet therapy for patients with CAD, with emphasis on those presenting with an acute coronary syndrome and undergoing percutaneous coronary revascularization. The aim is to provide clinicians with a comprehensive understanding of personalised antiplatelet therapy and facilitate informed clinical decision-making.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria 'G. Rodolico - San Marco', University of Catania, Via Santa Sofia, 78 - 95123 Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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17
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Mendieta G, Mehta S, Baber U, Angiolillo DJ, Briguori C, Cohen D, Collier T, Dangas G, Dudek D, Escaned J, Gil R, Vogel B, Cao D, Spirito A, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Moliterno DJ, Ohman EM, Sardella G, Sartori S, Sharma S, Shlofmitz R, Steg PG, Han YL, Pocock S, Gibson CM, Mehran R. Bleeding and Ischemic Risks of Ticagrelor Monotherapy After Coronary Interventions. J Am Coll Cardiol 2023; 82:687-700. [PMID: 37587580 DOI: 10.1016/j.jacc.2023.05.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/09/2023] [Accepted: 05/31/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND In TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention), among high-risk patients undergoing percutaneous coronary intervention (PCI), ticagrelor monotherapy vs continuation of dual antiplatelet therapy (DAPT) with aspirin and ticagrelor after completing a 3-month course of DAPT was associated with reduced bleeding, without an increase in ischemic events. OBJECTIVES This investigation sought to study the clinical benefit of ticagrelor monotherapy vs DAPT by simultaneously modeling its associated potential bleeding benefits and ischemic harms on an individual patient basis. METHODS Multivariable Cox regression models for: 1) Bleeding Academic Research Consortium type 2, 3, or 5 (BARC-2/3/5); and 2) cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke (major adverse cardiac and cerebrovascular event [MACCE]) were developed using stepwise forward variable selection. The coefficients in the BARC-2/3/5 and MACCE models were used to calculate bleeding and ischemic risk scores, respectively, for each patient (excluding the coefficient for randomized treatment). RESULTS In the total study group (N = 7,119), BARC-2/3/5 occurred in 391 (5.5%) patients, and MACCE occurred in 258 (3.6%). There was a consistent reduction in bleeding events associated with ticagrelor monotherapy compared with DAPT across both bleeding and ischemic risk strata (P interaction = 0.54 and 0.11, respectively). Importantly, this benefit associated with ticagrelor monotherapy was not offset by an increase in MACCE at any level of bleeding or ischemic risk. CONCLUSIONS Three months after PCI, discontinuing aspirin and maintaining ticagrelor monotherapy reduces bleeding in both higher-bleeding risk and lower-bleeding risk patients compared with continued DAPT. This benefit does not appear to be offset by greater ischemic risk. (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention [TWILIGHT]; NCT02270242).
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Affiliation(s)
- Guiomar Mendieta
- National Center of Cardiovascular Investigations Carlos III (CNIC), Madrid, Spain
| | - Shamir Mehta
- Department of Cardiology, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Usman Baber
- Cardiovascular Disease Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - David Cohen
- Department of Cardiology, St Francis Hospital, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dariusz Dudek
- 2nd Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Health Research Institute, San Carlos Clinical Hospital (IDISCC), Complutense University of Madrid, Madrid, Spain
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kurt Huber
- Third Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - Adnan Kastrati
- German Heart Center Munich, Technical University of Munich, German Center for Cardiovascular Research (DZHK) partner site Munich Heart Alliance, Munich, Germany
| | - Upendra Kaul
- Batra Hospital and Medical Research Center, New Delhi, India
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David J Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gennaro Sardella
- Department of Cardiology, Umberto I Polyclinical University, Rome, Italy
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Shlofmitz
- Department of Cardiology, St Francis Hospital, Roslyn, New York, USA
| | - P Gabriel Steg
- Paris Cité University, Public Hospitals of Paris (AP-HP), Bichat Hospital, Paris, France
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Shenyang Military Region, Shenyang, Liaoning, China
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - C Michael Gibson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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18
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Gigante B, Levy JH, van Gorp E, Bartoloni A, Bochaton-Piallat ML, Bäck M, Ten Cate H, Christersson C, Ferreiro JL, Geisler T, Lutgens E, Schulman S, Storey RF, Thachil J, Vilahur G, Liaw PC, Rocca B. Management of patients on antithrombotic therapy with severe infections: a joint clinical consensus statement of the ESC Working Group on Thrombosis, the ESC Working Group on Atherosclerosis and Vascular Biology, and the International Society on Thrombosis and Haemostasis. Eur Heart J 2023; 44:3040-3058. [PMID: 37439553 DOI: 10.1093/eurheartj/ehad388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 05/01/2023] [Accepted: 05/29/2023] [Indexed: 07/14/2023] Open
Abstract
Patients with severe infections and a pre-existing indication for antithrombotic therapy, i.e. antiplatelet agents, anticoagulant drugs, or their combinations, require integrated clinical counselling among coagulation, infectious disease, and cardiology specialists, due to sepsis-induced coagulopathy that frequently occurs. Bacterial and viral pathogens constitute an increasing threat to global public health, especially for patients with ongoing antithrombotic treatment who have a high risk of thrombotic recurrences and high susceptibility to severe infections with increased morbidity and mortality. Similarly, sepsis survivors are at increased risk for major vascular events. Coagulopathy, which often complicates severe infections, is associated with a high mortality and obligates clinicians to adjust antithrombotic drug type and dosing to avoid bleeding while preventing thrombotic complications. This clinical consensus statement reviews the best available evidence to provide expert opinion and statements on the management of patients hospitalized for severe bacterial or viral infections with a pre-existing indication for antithrombotic therapy (single or combined), in whom sepsis-induced coagulopathy is often observed. Balancing the risk of thrombosis and bleeding in these patients and preventing infections with vaccines, if available, are crucial to prevent events or improve outcomes and prognosis.
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Affiliation(s)
- Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solnavägen 30. 17164 and Department of Cardiology, Danderyds Hospital, Entrévägen 2, 182 88, Stockholm, Sweden
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, United States; 2301 Erwin Road, Durham, NC 27710, USA
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC, Rotterdam, PO box 2040 [Room Ee1726], 3000 CA Rotterdam, The Netherlands
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, Infectious Diseases Unit, University of Florence, Largo Brambilla 3, 50100 Florence, Italy
| | - Marie-Luce Bochaton-Piallat
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, 1 rue Michel-Servet 1, CH-1211 Genève, Switzerland
| | - Magnus Bäck
- Department of Translational Cardiology, Karolinska Institutet and Karolinska University Hospital, CMM L8:01, 171 76 Stockholm, Sweden
- INSERM U1116, University of Lorraine, Nancy University Hospital, 2 rue Jean Lamour, 54505 Vandoeuvre les Nancy Cedex, France
| | - Hugo Ten Cate
- Department of Internal medicine, Thrombosis Expertise Center, Maastricht University Medical Center and CARIM school for cardiovascular diseases, Universiteitsingel 50, PO Box 616, 6200 MD Maastricht, The Netherlands
- Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Langenbeckstr. 1, Bldg. 403, 55131 Mainz, Germany
| | - Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 75185, Uppsala, Sweden
| | - José Luis Ferreiro
- Department of Cardiology and Bio-Heart Cardiovascular Diseases Research Group; Bellvitge University Hospital - Bellvitge Biomedical Research Institute (IDIBELL); CIBERCV; L'Hospitalet de Llobregat, Hospital Duran i Reynals - Edifici Terapèutic - 2a planta Gran Via de l'Hospitalet, 199, 08908 Hospitalet de Llobregat Barcelona -Spain
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Esther Lutgens
- Cardiovascular Medicine, Experimental CardioVascular Immunology Laboratory, Mayo Clinic, 200 First St SW, 55905, Rochester, MN, USA
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians Universität, München, Germany & German Center for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Pettenkoferstrasse 9, 80336, Munich, Germany
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada HHS - General Hospital 237, Barton Street East, Hamilton, ON, L8L 2X2, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 2, стр. 4, Moscow 119435, Russia
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Pegasus House, 463a Glossop Road, Sheffield, S10 2QD, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford road, Manchester, M13 9WL, UK
| | - Gemma Vilahur
- Institut de Recerca Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, CIBERCV, Avda. Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - Patricia C Liaw
- Department of Medicine, Thrombosis & Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton Street East Hamilton, Ontario L8L 2X2, Canada
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
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19
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Gragnano F, Cao D, Pirondini L, Franzone A, Kim HS, von Scheidt M, Pettersen AÅR, Zhao Q, Woodward M, Chiarito M, McFadden EP, Park KW, Kastrati A, Seljeflot I, Zhu Y, Windecker S, Kang J, Schunkert H, Arnesen H, Bhatt DL, Steg PG, Calabrò P, Pocock S, Mehran R, Valgimigli M. P2Y 12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events. J Am Coll Cardiol 2023; 82:89-105. [PMID: 37407118 DOI: 10.1016/j.jacc.2023.04.051] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents. OBJECTIVES This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD. METHODS We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis. RESULTS Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (HR: 0.77; 95% CI: 0.66-0.90; P < 0.001). Major bleeding was similar (HR: 0.87; 95% CI: 0.70-1.09; P = 0.23) and net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors. CONCLUSIONS Given its superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Franzone
- Department of Advanced Biomedical Sciences Federico II University of Naples, Naples, Italy
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Alf-Åge R Pettersen
- Department of Cardiology, Ringerike Hospital, Vestre Viken HF, Drammen, Norway; Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Eugene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Kyung Woo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jeehoon Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, INSERM Unité 1148, Paris, France
| | - Paolo Calabrò
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
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20
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [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: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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21
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Falco L, Tessitore V, Ciccarelli G, Malvezzi M, D'Andrea A, Imbalzano E, Golino P, Russo V. Antioxidant Properties of Oral Antithrombotic Therapies in Atherosclerotic Disease and Atrial Fibrillation. Antioxidants (Basel) 2023; 12:1185. [PMID: 37371915 DOI: 10.3390/antiox12061185] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The thrombosis-related diseases are one of the leading causes of illness and death in the general population, and despite significant improvements in long-term survival due to remarkable advances in pharmacologic therapy, they continue to pose a tremendous burden on healthcare systems. The oxidative stress plays a role of pivotal importance in thrombosis pathophysiology. The anticoagulant and antiplatelet drugs commonly used in the management of thrombosis-related diseases show several pleiotropic effects, beyond the antithrombotic effects. The present review aims to describe the current evidence about the antioxidant effects of the oral antithrombotic therapies in patients with atherosclerotic disease and atrial fibrillation.
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Affiliation(s)
- Luigi Falco
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Viviana Tessitore
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Giovanni Ciccarelli
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Marco Malvezzi
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | | | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Paolo Golino
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
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22
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El Abdallaoui OEA, Tornyos D, Lukács R, Szabó D, Komócsi A. Individualized or Uniform De-Escalation Strategies for Antiplatelet Therapy in Acute Coronary Syndrome: A Review of Clinical Trials with Platelet Function Testing and Genetic Testing-Based Protocols. Int J Mol Sci 2023; 24:ijms24109071. [PMID: 37240417 DOI: 10.3390/ijms24109071] [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: 04/22/2023] [Revised: 05/13/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
This comprehensive literature review assessed the effectiveness of precision medicine approaches in individualizing P2Y12 de-escalation strategies, such as platelet function testing guidance, genetic testing guidance, and uniform de-escalation, for acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Analyzing six trials with a total of 13,729 patients, the cumulative analyses demonstrated a significant reduction in major adverse cardiac events (MACE), net adverse clinical events (NACE), and major and minor bleeding events with P2Y12 de-escalation. Specifically, the analysis found a 24% reduction of MACE and a 22% reduction of adverse event risk (relative risk (RR) 0.76, 95% confidence interval (CI): 0.71-0.82, and RR: 0.78, 95% CI 0.67-0.92, respectively). Reductions in bleeding events were highest with uniform unguided de-escalation, followed by guided de-escalations, while ischemic event rates were similarly lower across all three strategies. Although the review highlights the potential of individualized P2Y12 de-escalation strategies to offer a safer alternative to the long-term potent P2Y12 inhibitor-based dual antiplatelet therapy, it also indicates that laboratory-guided precision medicine approaches may not yet offer the expected benefits, necessitating further research to optimize individualized strategies and evaluate the potential of precision medicine approaches in this context.
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Affiliation(s)
| | - Dániel Tornyos
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Réka Lukács
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Dóra Szabó
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, 7624 Pécs, Hungary
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23
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Piccolo R, Esposito G. The conundrum of percutaneous coronary intervention without aspirin: a call for clarity. EUROINTERVENTION 2023; 19:13-14. [PMID: 37170566 PMCID: PMC10173752 DOI: 10.4244/eij-e-23-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Gurbel P, Tantry U, Guimarães PO, Lemos PA. Aspirin should be stopped at day 0 after PCI: pros and cons. EUROINTERVENTION 2023; 18:e1304-e1306. [PMID: 37025087 PMCID: PMC10068855 DOI: 10.4244/eij-e-23-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Paul Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Udaya Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | | | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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25
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Greco A, Finocchiaro S, Angiolillo DJ, Capodanno D. Advances in the available pharmacotherapy for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Expert Opin Pharmacother 2023; 24:453-471. [PMID: 36693142 DOI: 10.1080/14656566.2023.2171788] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Non-ST-segment elevation acute coronary syndromes (NSTE-ACS), including non-ST-segment-elevation myocardial infarction (NSTEMI) and unstable angina, represent a leading cause of mortality worldwide, with important socio-economic consequences. NSTEMI accounts for the majority of acute coronary syndromes and usually develops on the background of a nonocclusive thrombus. We searched for relevant literature in the field in PubMed and clinicaltrials.gov as of July 2022. AREAS COVERED A number of pharmacotherapies are currently available for treatment and secondary prevention, mainly including antithrombotic, lipid-lowering and anti-inflammatory drugs. Pretreatment with aspirin, anticoagulant and statin therapy is of key importance in the preprocedural phase, while pretreating with an oral P2Y12 inhibitor is not routinely indicated in patients undergoing early invasive management. For patients undergoing percutaneous coronary revascularization, pharmacotherapy essentially consists of antithrombotic drugs, which should be carefully selected. Finally, antithrombotic, lipid-lowering and anti-inflammatory drugs are important components of long-term secondary prevention after a NSTE-ACS. EXPERT OPINION This article reviews the evidence supporting recommendation on pharmacotherapy in patients presenting with a NSTE-ACS. Several randomized clinical trials are still ongoing and are expected to further inform scientific knowledge and clinical practice, with the final aim to improve the treatment of NSTE-ACS patients.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
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26
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Gragnano F, Mehran R, Branca M, Franzone A, Baber U, Jang Y, Kimura T, Hahn JY, Zhao Q, Windecker S, Gibson CM, Kim BK, Watanabe H, Song YB, Zhu Y, Vranckx P, Mehta S, Hong SJ, Ando K, Gwon HC, Calabrò P, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Valgimigli M. P2Y 12 Inhibitor Monotherapy or Dual Antiplatelet Therapy After Complex Percutaneous Coronary Interventions. J Am Coll Cardiol 2023; 81:537-552. [PMID: 36754514 DOI: 10.1016/j.jacc.2022.11.041] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/20/2022] [Accepted: 11/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND It remains unclear whether P2Y12 inhibitor monotherapy preserves ischemic protection while limiting bleeding risk compared with dual antiplatelet therapy (DAPT) after complex percutaneous coronary intervention (PCI). OBJECTIVES We sought to assess the effects of P2Y12 inhibitor monotherapy after 1-month to 3-month DAPT vs standard DAPT in relation to PCI complexity. METHODS We pooled patient-level data from randomized controlled trials comparing P2Y12 inhibitor monotherapy and standard DAPT on centrally adjudicated outcomes after coronary revascularization. Complex PCI was defined as any of 6 criteria: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, or chronic total occlusion. The primary efficacy endpoint was all-cause mortality, myocardial infarction, and stroke. The key safety endpoint was Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding. RESULTS Of 22,941 patients undergoing PCI from 5 trials, 4,685 (20.4%) with complex PCI had higher rates of ischemic events. The primary efficacy endpoint was similar between P2Y12 inhibitor monotherapy and DAPT among patients with complex PCI (HR: 0.87; 95% CI: 0.64-1.19) and noncomplex PCI (HR: 0.91; 95% CI: 0.76-1.09; Pinteraction = 0.770). The treatment effect was consistent across all the components of the complex PCI definition. Compared with DAPT, P2Y12 inhibitor monotherapy consistently reduced BARC 3 or 5 bleeding in complex PCI (HR: 0.51; 95% CI: 0.31-0.84) and noncomplex PCI patients (HR: 0.49; 95% CI: 0.37-0.64; Pinteraction = 0.920). CONCLUSIONS P2Y12 inhibitor monotherapy after 1-month to 3-month DAPT was associated with similar rates of fatal and ischemic events and lower risk of major bleeding compared with standard DAPT, irrespective of PCI complexity. (PROSPERO [P2Y12 Inhibitor Monotherapy Versus Standard Dual Antiplatelet Therapy After Coronary Revascularization: Individual Patient Data Meta-Analysis of Randomized Trials]; CRD42020176853).
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Takeshi Kimura
- Kyoto University Graduate School of Medicine, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Charles M Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Byeong-Keuk Kim
- Department of Cardiology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Hirotoshi Watanabe
- Kyoto University Graduate School of Medicine, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium; Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sung-Jin Hong
- Department of Cardiology, CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Kenji Ando
- Kokura Memorial Hospital, Department of Cardiology, Kitakyushu, Japan
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland; NHLI, Imperial College London, London, United Kingdom
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Dik Heg
- Clinical Trials Unit, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
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27
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De Servi S, Landi A, Savonitto S, De Luca L, De Luca G, Morici N, Montalto C, Crimi G, Cattaneo M. Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice. J Cardiovasc Med (Hagerstown) 2023; 24:77-86. [PMID: 36583976 DOI: 10.2459/jcm.0000000000001399] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The assessment of bleeding and ischemic risk is a crucial step in establishing appropriate composition and duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary angioplasty. Evidence from recent randomized clinical trials led to some paradigm shifts in current guidelines recommendations. Options alternative to the standard 12-month DAPT duration include shorter periods of DAPT followed by single antiplatelet treatment with either aspirin or P2Y12 monotherapy, guided or unguided de-escalation DAPT, prolonged DAPT beyond the 12-month treatment period. Although DAPT composition and duration should be selected for each ACS patient on an individual basis weighing clinical and procedural variables, data from latest trials and meta-analyses may permit suggesting the most appropriate DAPT strategy according to the ischemic and bleeding risk assessed using validated tools and scores.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | | | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, Roma
| | - Giuseppe De Luca
- Clinical and Experimental Cardiology Unit, Azienda Ospedaliera-Universitaria di Sassari, University of Sassari, Sassari.,Clinical and Interventional Cardiology, Istituto Clinico Sant'Ambrogio, Gruppo San Donato
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, Milan
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genova
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28
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Capodanno D, Angiolillo DJ. Long-Term P2Y 12 Inhibitor or Aspirin as Single Antiplatelet Therapy in Patients With Previous Percutaneous Coronary Intervention. Circulation 2023; 147:118-121. [PMID: 36622905 DOI: 10.1161/circulationaha.122.063004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico Gaspare Rodolico-San Marco, University of Catania, Italy (D.C.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
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29
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Capodanno D, Angiolillo DJ. Timing, Selection, Modulation, and Duration of P2Y 12 Inhibitors for Patients With Acute Coronary Syndromes Undergoing PCI. JACC Cardiovasc Interv 2023; 16:1-18. [PMID: 36599574 DOI: 10.1016/j.jcin.2022.10.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 01/04/2023]
Abstract
Dual antiplatelet therapy with aspirin and the oral P2Y12 inhibitor clopidogrel as the cornerstone of treatment for patients with an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) was firstly established in 2001. Soon thereafter, the newer-generation P2Y12 inhibitors prasugrel and ticagrelor became commercially available. The clinical management of ACS patients undergoing PCI has evolved significantly in the last 2 decades, with a shift toward more rapid invasive management, broader use of drug-eluting stents, and the increasing recognition that major bleeding due to antiplatelet therapy is detrimental. In this ever-changing scenario, numerous studies have addressed 4 main questions regarding P2Y12 inhibition in ACS patients undergoing PCI: timing, selection, modulation, and duration. This paper reviews the latest evidence surrounding these topical questions, with a focus on efficacy and safety data, practice guidelines, and residual areas of uncertainty.
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Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico "Gaspare Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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30
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Yamamoto K, Watanabe H, Morimoto T, Obayashi Y, Natsuaki M, Yamaji K, Domei T, Ogita M, Ohya M, Tatsushima S, Suzuki H, Tada T, Ishii M, Nikaido A, Watanabe N, Fujii S, Mori H, Nishikura T, Suematsu N, Hayashi F, Komiyama K, Shigematsu T, Isawa T, Suwa S, Ando K, Kimura T. Clopidogrel Monotherapy After 1-Month Dual Antiplatelet Therapy in Patients With Diabetes Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:19-31. [PMID: 36599584 DOI: 10.1016/j.jcin.2022.09.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/08/2022] [Accepted: 09/27/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetes was reported to be associated with an impaired response to clopidogrel. OBJECTIVES The aim of this study was to evaluate the safety and efficacy of clopidogrel monotherapy after very short dual antiplatelet therapy (DAPT) in patients with diabetes undergoing percutaneous coronary intervention (PCI). METHODS A subgroup analysis was conducted on the basis of diabetes in the STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2) Total Cohort (N = 5,997) (STOPDAPT-2, n = 3,009; STOPDAPT-2 ACS [Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS], n = 2,988), which randomly compared 1-month DAPT followed by clopidogrel monotherapy with 12-month DAPT with aspirin and clopidogrel after cobalt-chromium everolimus-eluting stent implantation. The primary endpoint was a composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) or bleeding (TIMI [Thrombolysis In Myocardial Infarction] major or minor) endpoints at 1 year. RESULTS There were 2,030 patients with diabetes (33.8%) and 3967 patients without diabetes (66.2%). Regardless of diabetes, the risk of 1-month DAPT relative to 12-month DAPT was not significant for the primary endpoint (diabetes, 3.58% vs 4.12% [HR: 0.87; 95% CI: 0.56-1.37; P = 0.55]; nondiabetes, 2.46% vs 2.49% [HR: 0.99; 95% CI: 0.67-1.48; P = 0.97]; Pinteraction = 0.67) and for the cardiovascular endpoint (diabetes, 3.28% vs 3.05% [HR: 1.10; 95% CI: 0.67-1.81; P = 0.70]; nondiabetes, 1.95% vs 1.43% [HR: 1.38; 95% CI: 0.85-2.25; P = 0.20]; Pinteraction = 0.52), while it was lower for the bleeding endpoint (diabetes, 0.30% vs 1.50% [HR: 0.20; 95% CI: 0.06-0.68; P = 0.01]; nondiabetes, 0.61% vs 1.21% [HR: 0.51; 95% CI: 0.25-1.01; P = 0.054]; Pinteraction = 0.19). CONCLUSIONS Clopidogrel monotherapy after 1-month DAPT compared with 12-month DAPT reduced major bleeding events without an increase in cardiovascular events regardless of diabetes, although the findings should be considered as hypothesis generating, especially in patients with acute coronary syndrome, because of the inconclusive result in the STOPDAPT-2 ACS trial. (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 [STOPDAPT-2], NCT02619760; Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2 for the Patients With ACS [STOPDAPT-2 ACS], NCT03462498).
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. https://twitter.com/KoYamamoto7
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan. https://twitter.com/HirotWatanabeMD
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shojiro Tatsushima
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hirohiko Suzuki
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akira Nikaido
- Department of Cardiology, Minamino Cardiovascular Hospital, Hachioji, Japan
| | - Naoki Watanabe
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Shinya Fujii
- Department of Cardiology, Sendai Cardiovascular Center, Sendai, Japan
| | - Hiroyoshi Mori
- Department of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Tenjin Nishikura
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Nobuhiro Suematsu
- Division of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Fujio Hayashi
- Division of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Kota Komiyama
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Tatsuya Shigematsu
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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31
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Zhou X, Angiolillo DJ, Ortega-Paz L. P2Y 12 Inhibitor Monotherapy after Percutaneous Coronary Intervention. J Cardiovasc Dev Dis 2022; 9:jcdd9100340. [PMID: 36286292 PMCID: PMC9604207 DOI: 10.3390/jcdd9100340] [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: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
In patients with acute and chronic coronary artery disease undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) has been the cornerstone of pharmacotherapy for the past two decades. Although its antithrombotic benefit is well established, DAPT is associated with an increased risk of bleeding, which is independently associated with poor prognosis. The improvement of the safety profiles of drug-eluting stents has been critical in investigating and implementing shorter DAPT regimens. The introduction into clinical practice of newer generation oral P2Y12 inhibitors such as prasugrel and ticagrelor, which provide more potent and predictable platelet inhibition, has questioned the paradigm of standard DAPT durations after coronary stenting. Over the last five years, several trials have assessed the safety and efficacy of P2Y12 inhibitor monotherapy after a short course of DAPT in patients treated with PCI. Moreover, ongoing studies are testing the role of P2Y12 inhibitor monotherapy immediately after PCI in selected patients. In this review, we provide up-to-date evidence on the efficacy and safety of P2Y12 inhibitor monotherapy after a short period of DAPT compared to DAPT in patients undergoing PCI as well as outcomes associated with P2Y12 inhibitor monotherapy compared to aspirin for long-term prevention.
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Affiliation(s)
- Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Department of Internal Medicine, University of Alabama at Birmingham Montgomery, Montgomery, AL 36116, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Correspondence: ; Tel.: +1-904-244-3378; Fax: +1-904-244-3102
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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32
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Mazzone PM, Angiolillo DJ, Capodanno D. Approaches to de-escalation of antiplatelet treatment in stabilized post-myocardial infarction patients with high ischemic risk. Expert Rev Cardiovasc Ther 2022; 20:839-849. [DOI: 10.1080/14779072.2022.2137492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco” University of Catania, Catania, Italy
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33
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Ayonrinde OT, Sanfilippo FM, Schultz C. Prescribing aspirin to older people - where is the line between cardiovascular benefit and upper gastrointestinal bleeding risk? Intern Med J 2022; 52:1468-1470. [PMID: 36100571 DOI: 10.1111/imj.15905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Oyekoya T Ayonrinde
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia.,Pharmacy Department, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Carl Schultz
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Cardiology Department, Royal Perth Hospital, Perth, Western Australia, Australia
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