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Zuccarelli V, Andreaggi S, Walsh JL, Kotronias RA, Chu M, Vibhishanan J, Banning AP, De Maria GL. Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention? J Clin Med 2024; 13:2923. [PMID: 38792463 PMCID: PMC11122374 DOI: 10.3390/jcm13102923] [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: 04/19/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.
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Affiliation(s)
- Vittorio Zuccarelli
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
| | - Stefano Andreaggi
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Jason L. Walsh
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Miao Chu
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Jonathan Vibhishanan
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
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Kaufmann CC, Muthspiel M, Lunzer L, Pogran E, Zweiker D, Burger AL, Wojta J, Huber K. Antiplatelet Therapy and Anticoagulation before, during, and after Acute Coronary Syndrome. J Clin Med 2024; 13:2313. [PMID: 38673585 PMCID: PMC11051414 DOI: 10.3390/jcm13082313] [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: 03/14/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Acute coronary syndrome (ACS) remains a major challenge in clinical practice, requiring rapid and effective antithrombotic treatment to mitigate adverse ischemic events while minimizing the risk of bleeding. In recent years, results from several clinical trials addressing this issue through various approaches have substantially improved the treatment landscape for patients presenting with ACS. The emergence of new, potent P2Y12 inhibitors has significantly enhanced thrombotic risk reduction and different strategies for de-escalating and shortening dual antiplatelet therapy (DAPT) have demonstrated promising outcomes in reducing bleeding rates. Furthermore, data from ongoing trials focusing on novel therapeutic agents and investigating alternative treatment strategies to optimize outcomes for ACS patients are expected in the next few years. In this review, we summarize the current knowledge and emphasize the critical role of individualized treatment approaches tailored to patient-specific risk factors and individual clinical scenarios.
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Affiliation(s)
- Christoph C. Kaufmann
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, A-1020 Vienna, Austria
| | - Marie Muthspiel
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, A-1020 Vienna, Austria
| | - Laura Lunzer
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
| | - Edita Pogran
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, A-1020 Vienna, Austria
| | - David Zweiker
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
| | - Achim Leo Burger
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, A-1020 Vienna, Austria
| | - Johann Wojta
- Ludwig Boltzmann Institute for Cardiovascular Research, A-1090 Vienna, Austria;
- Core Facilities, Medical University of Vienna, A-1090 Vienna, Austria
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Kurt Huber
- 3rd Medical Department with Cardiology and Intensive Care Medicine, Klinik Ottakring (Wilhelminenhospital), A-1160 Vienna, Austria; (M.M.); (L.L.); (E.P.); (D.Z.); (A.L.B.); (K.H.)
- Faculty of Medicine, Sigmund Freud University, A-1020 Vienna, Austria
- Ludwig Boltzmann Institute for Cardiovascular Research, A-1090 Vienna, Austria;
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Russo I, Brookles CG, Barale C, Melchionda E, Mousavi AH, Biolè C, Chinaglia A, Bianco M. Current Strategies to Guide the Antiplatelet Therapy in Acute Coronary Syndromes. Int J Mol Sci 2024; 25:3981. [PMID: 38612792 PMCID: PMC11011739 DOI: 10.3390/ijms25073981] [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: 02/18/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
The role of antiplatelet therapy in patients with acute coronary syndromes is a moving target with considerable novelty in the last few years. The pathophysiological basis of the treatment depends on platelet biology and physiology, and the interplay between these aspects and clinical practice must guide the physician in determining the best therapeutic options for patients with acute coronary syndromes. In the present narrative review, we discuss the latest novelties in the antiplatelet therapy of patients with acute coronary syndromes. We start with a description of platelet biology and the role of the main platelet signal pathways involved in platelet aggregation during an acute coronary syndrome. Then, we present the latest evidence on the evaluation of platelet function, focusing on the strengths and weaknesses of each platelet's function test. We continue our review by describing the role of aspirin and P2Y12 inhibitors in the treatment of acute coronary syndromes, critically appraising the available evidence from clinical trials, and providing current international guidelines and recommendations. Finally, we describe alternative therapeutic regimens to standard dual antiplatelet therapy, in particular for patients at high bleeding risk. The aim of our review is to give a comprehensive representation of current data on antiplatelet therapy in patients with acute coronary syndromes that could be useful both for clinicians and basic science researchers to be up-to-date on this complex topic.
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Affiliation(s)
- Isabella Russo
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Carola Griffith Brookles
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
- Department of Medical Sciences, University of Turin, I-10124 Turin, Italy
| | - Cristina Barale
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Elena Melchionda
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Amir Hassan Mousavi
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
- Department of Medical Sciences, University of Turin, I-10124 Turin, Italy
| | - Carloalberto Biolè
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
| | - Alessandra Chinaglia
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
| | - Matteo Bianco
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
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4
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Schäfer A. [Antithrombotic therapy in acute coronary syndrome]. Dtsch Med Wochenschr 2024; 149:496-501. [PMID: 38621683 DOI: 10.1055/a-2171-6892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Dual antiplatelet therapy (DAPT) is the cornerstone of maintenance medication following acute coronary syndromes (ST elevation myocardial infarction, non-ST elevation myocardial infarction, unstable angina). Over the last decade, P2Y12 inhibition in addition to low-dose acetylsalicylic acid has been intensively debated. In patients with acute coronary syndromes, balancing the reduction in cardiovascular events and increase in major bleeding during treatment with more potent P2Y12 inhibitors such as prasugrel and ticagrelor is still an issue. A special focus is on patients already treated with oral anticoagulants for stroke prevention in atrial fibrillation who require additional platelet inhibition following coronary stenting. This article summarizes the major recommendations given in the most recent Guideline for "Acute Coronary Syndromes" published by the European Society of Cardiology (ESC). The recommendations finally address strategies to reduce an increased bleeding risk based on clinical predictors.
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Karaca OF, Cimci M, Raimoglou D, Durmaz E, Yalman H, Tekin AM, Incesu G, Ozkan FU, Yavuz B, Karadag B. Impact of Preloading Strategy With Ticagrelor on Periprocedural Myocardial Injury in Patients With Non-ST Elevation Myocardial Infarction Undergoing Early Invasive Strategy. J Cardiovasc Pharmacol 2024; 83:311-316. [PMID: 38241694 DOI: 10.1097/fjc.0000000000001540] [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: 10/11/2023] [Accepted: 01/04/2024] [Indexed: 01/21/2024]
Abstract
ABSTRACT Pretreatment with an oral P2Y12 receptor blocker (before coronary angiography) versus treatment in the catheterization laboratory has been a matter of debate in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI). The primary aim of this study was to assess the impact of an immediate preloading strategy with ticagrelor on periprocedural myocardial injury in patients with NSTEMI treated with an early invasive strategy. NSTEMI patients who underwent coronary angiography and subsequent percutaneous coronary intervention (PCI) within 24 hours after hospital admission were divided into 2 groups: the first group (pretreatment group) included patients who received ticagrelor pretreatment as soon as possible after admission and the second group (no pretreatment group) included patients who received a loading dose of ticagrelor after coronary angiography. The pretreatment group included 232 patients, and the no pretreatment group included 87 patients. Male patients represented the majority of the patients. The 2 groups were similar in baseline characteristics, except for a greater incidence of hypertension ( P = 0.014) and higher hemoglobin levels ( P = 0.01) in the pretreatment group in comparison with the no pretreatment group. Patients in the ticagrelor pretreatment group had less myocardial injury until coronary angiography based on troponin measurements collected at 12 hours after admission ( P = 0.025). Patients in the ticagrelor pretreatment group also had fewer periprocedural myocardial injuries based on troponin measurements taken between 12 and 24 hours after the PCI ( P = 0.026 and P = 0.022, respectively). Our findings suggested that ticagrelor pretreatment reduces periprocedural myocardial injury in NSTEMI patients who underwent PCI within 24 hours after admission.
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Affiliation(s)
- Orhan Furkan Karaca
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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6
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Koliastasis L, Doundoulakis I, Xaplanteris P. Bending the Reluctance of No Pretreatment With P2Y 12 Inhibitors in ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2024; 17:822. [PMID: 38538178 DOI: 10.1016/j.jcin.2024.01.301] [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] [Received: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 04/05/2024]
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Licordari R, Costa F, Garcia-Ruiz V, Mamas MA, Marquis-Gravel G, de la Torre Hernandez JM, Gomez Doblas JJ, Jimenez-Navarro M, Rodriguez-Capitan J, Urbano-Carrillo C, Ortega-Paz L, Piccolo R, Versace AG, Di Bella G, Andò G, Angiolillo DJ, Valgimigli M, Micari A. The Evolving Field of Acute Coronary Syndrome Management: A Critical Appraisal of the 2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndrome. J Clin Med 2024; 13:1885. [PMID: 38610650 PMCID: PMC11012418 DOI: 10.3390/jcm13071885] [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: 02/19/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Acute coronary syndromes (ACS), encompassing conditions like ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndromes (NSTE-ACS), represent a significant challenge in cardiovascular care due to their complex pathophysiology and substantial impact on morbidity and mortality. The 2023 European Society of Cardiology (ESC) guidelines for ACS management introduce several updates in key areas such as invasive treatment timing in NSTE-ACS, pre-treatment strategies, approaches to multivessel disease, and the use of imaging modalities including computed tomography (CT) coronary angiography, magnetic resonance imaging (MRI), and intracoronary imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS). They also address a modulation of antiplatelet therapy, taking into consideration different patient risk profiles, and introduce new recommendations for low-dose colchicine. These guidelines provide important evidence-based updates in practice, reflecting an evolution in the understanding and management of ACS, yet some potentially missed opportunities for more personalized care and technology adoption are discussed.
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Affiliation(s)
- Roberto Licordari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
| | | | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele ST5 5BG, UK;
| | - Guillaume Marquis-Gravel
- Montréal Heart Institute, Faculty of Medicine, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | | | - Juan Jose Gomez Doblas
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | - Manuel Jimenez-Navarro
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | - Jorge Rodriguez-Capitan
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | | | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA (D.J.A.)
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | | | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (G.D.B.); (G.A.)
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (G.D.B.); (G.A.)
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA (D.J.A.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6500 Lugano, Switzerland;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
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Díez-Delhoyo F, López Lluva MT, Cepas-Guillén P, Jurado-Román A, Bazal-Chacón P, Negreira-Caamaño M, Olavarri-Miguel I, Elorriaga A, Fernández-Sánchez JA, Escribano D, Salinas P, Vaquero-Luna J, Prieto-Lobato A, Pérez-Cebey L, Carrasquer A, Llaóo I, Torres Mezcúa FJ, Giralt-Borrell T, Abellas M, García-Blas S, Matute-Blanco L, Robles-Gamboa C, Martínez-Guisado A, Fernández-Cordón C, González-Maniega C, Díez-Villanueva P. Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:234-242. [PMID: 38476000 DOI: 10.1016/j.rec.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/27/2023] [Indexed: 03/14/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.
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Affiliation(s)
| | | | | | | | - Pablo Bazal-Chacón
- Servicio de Cardiología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | | | - Iván Olavarri-Miguel
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Ane Elorriaga
- Servicio de Cardiología, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain
| | | | - David Escribano
- Servicio de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Pablo Salinas
- Servicio de Cardiología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | | | - Lucía Pérez-Cebey
- Servicio de Cardiología, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Anna Carrasquer
- Servicio de Cardiología, Hospital Joan XXIII, Tarragona, Spain
| | - Isaac Llaóo
- Servicio de Cardiología, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - María Abellas
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Lucía Matute-Blanco
- Servicio de Cardiología, Hospital Universitario Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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9
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Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Domei T, Suwa S, Ogita M, Isawa T, Takenaka H, Yamamoto T, Ishikawa T, Hisauchi I, Wakabayashi K, Onishi Y, Hibi K, Kawai K, Yoshida R, Suzuki H, Nakazawa G, Kusuyama T, Morishima I, Ono K, Kimura T. An Aspirin-Free Versus Dual Antiplatelet Strategy for Coronary Stenting: STOPDAPT-3 Randomized Trial. Circulation 2024; 149:585-600. [PMID: 37994553 DOI: 10.1161/circulationaha.123.066720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Bleeding rates on dual antiplatelet therapy (DAPT) within 1 month after percutaneous coronary intervention (PCI) remain high in clinical practice, particularly in patients with acute coronary syndrome or high bleeding risk. Aspirin-free strategy might result in lower bleeding early after PCI without increasing cardiovascular events, but its efficacy and safety have not yet been proven in randomized trials. METHODS We randomly assigned 6002 patients with acute coronary syndrome or high bleeding risk just before PCI either to prasugrel (3.75 mg/day) monotherapy or to DAPT with aspirin (81-100 mg/day) and prasugrel (3.75 mg/day) after loading of 20 mg of prasugrel in both groups. The coprimary end points were major bleeding (Bleeding Academic Research Consortium 3 or 5) for superiority and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke) for noninferiority with a relative 50% margin. RESULTS The full analysis set population consisted of 5966 patients (no-aspirin group, 2984 patients; DAPT group, 2982 patients; age, 71.6±11.7 years; men, 76.6%; acute coronary syndrome, 75.0%). Within 7 days before randomization, aspirin alone, aspirin with P2Y12 inhibitor, oral anticoagulants, and intravenous heparin infusion were given in 21.3%, 6.4%, 8.9%, and 24.5%, respectively. Adherence to the protocol-specified antiplatelet therapy was 88% in both groups at 1 month. At 1 month, the no-aspirin group was not superior to the DAPT group for the coprimary bleeding end point (4.47% and 4.71%; hazard ratio, 0.95 [95% CI, 0.75-1.20]; Psuperiority=0.66). The no-aspirin group was noninferior to the DAPT group for the coprimary cardiovascular end point (4.12% and 3.69%; hazard ratio, 1.12 [95% CI, 0.87-1.45]; Pnoninferiority=0.01). There was no difference in net adverse clinical outcomes and each component of coprimary cardiovascular end point. There was an excess of any unplanned coronary revascularization (1.05% and 0.57%; hazard ratio, 1.83 [95%CI, 1.01-3.30]) and subacute definite or probable stent thrombosis (0.58% and 0.17%; hazard ratio, 3.40 [95% CI, 1.26-9.23]) in the no-aspirin group compared with the DAPT group. CONCLUSIONS The aspirin-free strategy using low-dose prasugrel compared with the DAPT strategy failed to attest superiority for major bleeding within 1 month after PCI but was noninferior for cardiovascular events within 1 month after PCI. However, the aspirin-free strategy was associated with a signal suggesting an excess of coronary events. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04609111.
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Affiliation(s)
- Masahiro Natsuaki
- Department of Cardiovascular Medicine, Saga University, Japan (M.N.)
| | - Hirotoshi Watanabe
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (T.M.)
| | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan (S.S., M.O.)
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan (S.S., M.O.)
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Japan (T. Isawa)
| | - Hiroyuki Takenaka
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Takashi Yamamoto
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan (T. Ishikawa, I.H.)
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan (T. Ishikawa, I.H.)
| | - Kohei Wakabayashi
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan (K.W.)
| | - Yuko Onishi
- Department of Cardiology, Hiratsuka Kyosai Hospital, Japan (Y. Onishi)
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Japan (K.H.)
| | - Kazuya Kawai
- Division of Cardiology, Chikamori Hospital, Kochi, Japan (K.K.)
| | - Ruka Yoshida
- Division of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan (R.Y.)
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan (H.S.)
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan (G.N.)
| | - Takanori Kusuyama
- Division of Cardiology, Tsukazaki Hospital, Himeji, Japan (T. Kusuvama)
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.)
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
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10
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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11
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Bainey KR, Marquis-Gravel G, Belley-Côté E, Turgeon RD, Ackman ML, Babadagli HE, Bewick D, Boivin-Proulx LA, Cantor WJ, Fremes SE, Graham MM, Lordkipanidzé M, Madan M, Mansour S, Mehta SR, Potter BJ, Shavadia J, So DF, Tanguay JF, Welsh RC, Yan AT, Bagai A, Bagur R, Bucci C, Elbarouni B, Geller C, Lavoie A, Lawler P, Liu S, Mancini J, Wong GC. Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2024; 40:160-181. [PMID: 38104631 DOI: 10.1016/j.cjca.2023.10.013] [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: 09/17/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Emilie Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ricky D Turgeon
- University of British Columbia, St Paul's Hospital PHARM-HF Clinic, Vancouver, British Columbia, Canada
| | | | - Hazal E Babadagli
- Pharmacy Services, Alberta Health Services, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - David Bewick
- Division of Cardiology, Department of Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | | | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marie Lordkipanidzé
- Faculté de pharmacie, Université de Montréal, Research Center, Montréal Heart Institute, Montréal, Québec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jay Shavadia
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Derek F So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jean-François Tanguay
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T Yan
- Division of Cardiology, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Claudia Bucci
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Basem Elbarouni
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carol Geller
- University of Ottawa, Centretown Community Health Centre, Ottawa, Ontario, Canada
| | - Andrea Lavoie
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | - Patrick Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shuangbo Liu
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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12
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Chichareon P, Chamnarnphol N, Chandavimol M, Suwannasom P, Roongsangmanoon W, Limpijankit T, Srimahachota S, Athisakul S, Hutayanon P, Kiatchoosakun S, Udayachalerm W, Thakkinstian A, Sansanayudh N. Updated CRUSADE score to predict in-hospital bleeding: External validation in the Thai percutaneous coronary intervention registry. Catheter Cardiovasc Interv 2024; 103:268-275. [PMID: 38219275 DOI: 10.1002/ccd.30940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/09/2023] [Accepted: 12/10/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) score has been recommended to predict in-hospital bleeding risk in non-ST segment elevation myocardial infarction (NSTEMI) patients. The evaluation of the CRUSADE risk score in Asian patients undergoing contemporary percutaneous coronary intervention (PCI) for NSTEMI is necessary. AIMS We aimed to validate and update the CRUSADE score to predict in-hospital major bleeding in NSTEMI patients treated with PCI. METHOD The Thai PCI registry is a large, prospective, multicenter PCI registry in Thailand enrolling patients between May 2018 and August 2019. The CRUSADE score was calculated based on 8 predictors including sex, diabetes, prior vascular disease (PVD), congestive heart failure (CHF), creatinine clearance (CrCl), hematocrit, systolic blood pressure, and heart rate (HR). The score was fitted to in-hospital major bleeding using the logistic regression. The original score was revised and updated for simplification. RESULTS Of 19,701 patients in the Thai PCI registry, 5976 patients presented with NSTEMI. The CRUSADE score was calculated in 5882 patients who had all variables of the score available. Thirty-five percent were female, with a median age of 65.1 years. The proportion of diabetes, PVD, and CHF was 46%, 7.9%, and 11.2%, respectively. The original and revised models of the CRUSADE risk score had C-statistics of 0.817 (95% CI: 0.762-0.871) and 0.839 (95% CI: 0.789-0.889) respectively. The simplified CRUSADE score which contained only four variables (hematocrit, CrCl, HR, and CHF), had C-statistics of 0.837 (0.787-0.886). The calibration of the recalibrated, revised, and simplified model was optimal. CONCLUSIONS The full and simplified CRUSADE scores performed well in NSTEMI treated with PCI in Thai population.
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Affiliation(s)
- Ply Chichareon
- Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Noppadol Chamnarnphol
- Cardiology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Mann Chandavimol
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Salaya, Thailand
| | - Pannipa Suwannasom
- Northern Region Heart Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Thosaphol Limpijankit
- Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Salaya, Thailand
| | | | | | - Pisit Hutayanon
- Cardiology Unit, Department of Medicine, Thammasat University, Bangkok, Thailand
| | | | | | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Salaya, Thailand
| | - Nakarin Sansanayudh
- Cardiology Unit, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
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13
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Rohla M, Ye SX, Shibutani H, Bruno J, Otsuka T, Häner JD, Bär S, Temperli F, Kavaliauskaite R, Lanz J, Stortecky S, Praz F, Hunziker L, Pilgrim T, Siontis GC, Losdat S, Windecker S, Räber L. Pretreatment With P2Y 12 Inhibitors in ST-Segment Elevation Myocardial Infarction: Insights From the Bern-PCI Registry. JACC Cardiovasc Interv 2024; 17:17-28. [PMID: 38199749 DOI: 10.1016/j.jcin.2023.10.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/14/2023] [Accepted: 10/25/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Evidence to support immediate P2Y12 inhibitor loading in ST-segment elevation myocardial infarction (STEMI) is limited. OBJECTIVES This study sought to compare outcomes of STEMI patients receiving immediate or delayed P2Y12 inhibitor treatment. METHODS Using data from the prospective Bern-PCI registry between 2016 and 2020, we stratified STEMI patients undergoing percutaneous coronary intervention according to time periods with different institutional recommendations regarding P2Y12 inhibitor pretreatment. In cohort 1 (October 2016-September 2018), immediate P2Y12 inhibitor treatment was recommended. In cohort 2 (October 2018-September 2020), P2Y12 inhibitor treatment was recommended after coronary anatomy was confirmed. The primary endpoint was a composite of major adverse cardiac or cerebrovascular events (MACCEs) defined as all-cause death, recurrent myocardial infarction, stroke, or definite stent thrombosis at 30 days. Sensitivity analysis included only patients in whom these recommendations were followed. RESULTS Cohort 1 included 1,116 patients; pretreatment was actually given in 708 (63.4%). Cohort 2 included 847 patients; pretreatment was withheld in 798 (94.2%). The mean age was 65 ± 13 years, and 24% were female. Baseline characteristics were well-balanced between groups. The median difference for P2Y12 loading to angiography was 52 minutes between cohort 1 and 2 and 100 minutes between patients receiving vs not receiving pretreatment. Rates of MACCEs were similar between cohort 1 and cohort 2 (10.1% vs 8.1%; adjusted HR: 0.91; 95% CI: 0.65-1.28; P = 0.59) and between patients receiving vs not receiving pretreatment (7.1% vs 8.4%; adjusted HR: 1.17; 95% CI: 0.78-1.74; P = 0.45). CONCLUSIONS In this cohort study of patients with STEMI undergoing primary percutaneous coronary intervention, P2Y12 inhibitor pretreatment was not associated with improved MACCEs.
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Affiliation(s)
- Miklos Rohla
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Shirley Xinyu Ye
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Hiroki Shibutani
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland; Division of Cardiology, Department of Medicine II, Kansai Medical University, Hirakata, Japan
| | - Jolie Bruno
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Tatsuhiko Otsuka
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas D Häner
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Sarah Bär
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Fabrice Temperli
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Raminta Kavaliauskaite
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - George Cm Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Sylvain Losdat
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
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14
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Welsh RC. Antiplatelet Pretreatment Before Angiography With Anticipated or Planned Percutaneous Coronary Intervention in Stable Ischemic Heart Disease. Can J Cardiol 2024; 40:40-42. [PMID: 38013063 DOI: 10.1016/j.cjca.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Robert C Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada.
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15
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Mostafa MR, Eid MM, Awad AK, Takla A, Hassan AR, Katamesh BE, AlBarakat MM, Ziada AR, Mohamed S, Al-Azizi KM, Goldsweig AM. Safety and Efficacy of Cangrelor in Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. Am J Cardiovasc Drugs 2024; 24:71-81. [PMID: 37995040 DOI: 10.1007/s40256-023-00616-2] [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] [Accepted: 10/04/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Cangrelor is a potent intravenous non-thienopyridine P2Y12 inhibitor. We conducted a network meta-analysis to study the efficacy and safety of cangrelor as compared with the oral P2Y12 inhibition, clopidogrel, or placebo in acute coronary syndromes. METHODS This meta-analysis followed the Cochrane collaboration guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. Outcomes of interest included all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, major bleeding, minor bleeding, and the need for blood transfusion. RESULTS The analysis was comprised of 6 studies including 26,444 patients treated with cangrelor, clopidogrel, or placebo. There were no statistically significant differences in the incidence of all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, or major bleeding. Cangrelor was associated with a higher risk of minor bleeding than clopidogrel or placebo, with no difference in requiring blood transfusion. CONCLUSION Cangrelor has comparable outcomes to clopidogrel in patients with acute coronary syndromes and can be used as a reliable alternative in this population.
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Affiliation(s)
| | | | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Andrew Takla
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | | | | | - Majd M AlBarakat
- Faculty of Medicine, Jordan University of Science and Technology, Amman, Jordan
| | | | | | - Karim M Al-Azizi
- Baylor Scott and White Health-The Heart Hospital, Plano, TX, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA, USA
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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16
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Maqsood MH, Levine GN, Kleiman ND, Hasdai D, Uretsky BF, Birnbaum Y. Do We Still Need Aspirin in Coronary Artery Disease? J Clin Med 2023; 12:7534. [PMID: 38137601 PMCID: PMC10743767 DOI: 10.3390/jcm12247534] [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: 11/02/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Aspirin has for some time been used as a first-line treatment for acute coronary syndromes, including ST-elevation myocardial infarction, for secondary prevention of established coronary disease, and for primary prevention in patients at risk of coronary artery disease. Although aspirin has been in use for decades, the available evidence for its efficacy largely predates the introduction of other drugs, such as statins and P2Y12 inhibitors. Based on recent trials, the recommendation for aspirin use as primary prevention has been downgraded. In addition, P2Y12 inhibitors given as a single antiplatelet therapy have been associated with a lower incidence of bleeding than dual antiplatelet therapy in combination with aspirin in patients with stable and unstable coronary artery disease. The aim of this review is to discuss the role of aspirin considering the available evidence for primary prevention, secondary prevention for stable coronary artery disease or acute coronary syndromes, and after percutaneous coronary intervention or coronary artery bypass revascularization.
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Affiliation(s)
- Muhammad Haisum Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Methodist Hospital, Houston, TX 77030, USA;
| | - Glenn N. Levine
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Neal D. Kleiman
- Department of Cardiology, Section of Interventional Cardiology, Houston Methodist DeBakey Heart Center, Houston, TX 77030, USA;
| | - David Hasdai
- Department of Cardiology, Rabin Medical Center, Tel Aviv University, Petah Tikva 49200, Israel;
| | - Barry F. Uretsky
- Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
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17
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Fang Z, Lv B, Zhan J, Xing X, Ding C, Liu J, Wang L, Zou X, Qiu X. Flexible Conductive Decellularized Fish Skin Matrix as a Functional Scaffold for Myocardial Infarction Repair. Macromol Biosci 2023; 23:e2300207. [PMID: 37534715 DOI: 10.1002/mabi.202300207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/25/2023] [Indexed: 08/04/2023]
Abstract
Engineering cardiac patches are proven to be effective in myocardial infarction (MI) repair, but it is still a tricky problem in tissue engineering to construct a scaffold with good biocompatibility, suitable mechanical properties, and solid structure. Herein, decellularized fish skin matrix is utilized with good biocompatibility to prepare a flexible conductive cardiac patch through polymerization of polydopamine (PDA) and polypyrrole (PPy). Compared with single modification, the double modification strategy facilitated the efficiency of pyrrole polymerization, so that the patch conductivity is improved. According to the results of experiments in vivo and in vitro, the scaffold can promote the maturation and functionalization of cardiomyocytes (CMs). It can also reduce the inflammatory response, increase local microcirculation, and reconstruct the conductive microenvironment in infarcted myocardia, thus improving the cardiac function of MI rats. In addition, the excellent flexibility of the scaffold, which enables it to be implanted in vivo through "folding-delivering-re-stretehing" pathway, provides the possibility of microoperation under endoscope, which avoids the secondary damage to myocardium by traditional thoracotomy for implantation surgery.
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Affiliation(s)
- Zhanhong Fang
- The Seventh Affiliated Hospital, Southern Medical University, Foshan, Guangdong, 528244, China
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, School of Basic Medical Science, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Bingyang Lv
- The Seventh Affiliated Hospital, Southern Medical University, Foshan, Guangdong, 528244, China
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, School of Basic Medical Science, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jiamian Zhan
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, School of Basic Medical Science, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Xianglong Xing
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Chengbin Ding
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jianing Liu
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Leyu Wang
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, Biomaterials Research Center, School of Biomedical Engineering, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Xiaoming Zou
- The Seventh Affiliated Hospital, Southern Medical University, Foshan, Guangdong, 528244, China
| | - Xiaozhong Qiu
- Guangdong Provincial Key Laboratory of Construction and Detection in Tissue Engineering, School of Basic Medical Science, Southern Medical University, Guangzhou, Guangdong, 510515, China
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18
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Benenati S, De Maria GL, Della Mora F, Portolan L, Kotronias R, Kharbanda RK, Porto I, Banning AP. Periprocedural antithrombotic strategies in acute coronary syndromes undergoing percutaneous coronary intervention: Have we discarded bivalirudin too soon? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:70-79. [PMID: 37349187 DOI: 10.1016/j.carrev.2023.06.014] [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: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/14/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Publication of the BRIGHT-4 trial results has restimulated discussion about the optimal periprocedural antithrombotic strategy for patients undergoing percutaneous coronary intervention (PCI) with acute coronary syndromes (ACS). It is possible that variation in the infusion duration, may contribute to observed differences in safety-efficacy profiles of bivalirudin in this clinical setting. METHODS Up to December 2022, randomized controlled trials (RCTs) comparing bivalirudin (either administered peri-procedurally or accompanied by postprocedural infusion) and heparin, both with or without GPI, were searched and entered in a frequentist network meta-analysis. Co-primary endpoints were trial-defined major adverse composite events (MACE) and major bleeding. Incident rate ratios (IRR) and 95 % confidence intervals (CI) were estimated. RESULTS 10 RCTs (N = 57,137 patients/month) were included. As compared to heparin, prolonged bivalirudin infusion resulted in lower rates of major bleeding (IRR 0.58, 95 % CI 0.36-0.91), but there was no differences in MACE rates between these strategies. With regard to NACE, prolonged bivalirudin infusion yielded lower risk (IRR 0.86, 95 % CI 0.77-0.96), whereas both bivalirudin and heparin increased risk when coupled with GPI (IRR 1.24, 95 % CI 1.01-1.51 and IRR 1.24, 95 % CI 1.06-1.44, respectively). Both these combination strategies also increased minor bleeding rates (IRR 1.49, 95 % CI 1.16-1.93 and IRR 1.58, 95 % CI 1.29-1.95, respectively, for bivalirudin and heparin). Results were consistent across several sensitivity analyses. CONCLUSION In patients with ACS undergoing PCI, procedural bivalirudin administration followed by prolonged infusion results in lower major bleeding rates, but there does not appear to be a difference in observed MACE.
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Affiliation(s)
- Stefano Benenati
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Della Mora
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom; Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Leonardo Portolan
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom; Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Rafail Kotronias
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Rajesh K Kharbanda
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Italo Porto
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy; Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Adrian P Banning
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.
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19
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Liontou C, Kalogera V, Oikonomou D, Stalikas D, Pappas L, Triantafyllou K. Diagnostic performance of quantitative flow ratio in non-ST elevation acute coronary syndromes in comparison to non-hyperemic pressure ratios: a prospective study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2567-2574. [PMID: 37882959 DOI: 10.1007/s10554-023-02967-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
Quantitative flow ratio (QFR) is a new angiography-based coronary physiology tool aimed to evaluate functional relevance of intermediate coronary lesions. Aim of the study is to assess diagnostic performance of QFR in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in comparison to currently used non-hyperaemic pressure ratios (NHPRs). In this prospective, single-centre study, coronary physiology of intermediate coronary stenoses of non-culprit vessels in patients presenting with NSTE-ACS was evaluated using NHPRs (iFR, DFR or RFR). Subsequently, QFR was computed offline by a QFR analyst blinded to the NHPR results. Diagnostic performance of QFR was assessed in comparison to NHPRs as reference standard. A total of 60 vessels with intermediate coronary stenoses was investigated. The NHPRs were used as follows: RFR 38%, DFR 47% and iFR 15% of the cases. The NHPR result was positive, showing significant lesion, in 19 cases. A significant correlation was found between NHPR and QFR (r = 0.84, p < 0.001). Classification agreement of the two methods (95%) and diagnostic performance of QFR in comparison to NHPR (AUC: 0.962 [0.914-1.00]) were both high. Sensitivity, specificity, positive and negative predictive value of QFR in comparison to NHPR were 84.2%, 100%, 100% and 93.2% respectively. QFR has high diagnostic performance in detecting functionally significant lesions of non-culprit arteries in patients with NSTE-ACS and multivessel disease. Due to its high negative predictive value, it can be used to safely avoid unnecessary invasive physiological assessment of these lesions.
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Affiliation(s)
- Catherine Liontou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece.
| | - Vasiliki Kalogera
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Oikonomou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Stalikas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Loukas Pappas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
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Costa H, Espírito-Santo M, Fernandes R, Bispo J, Guedes J, Azevedo P, Carvalho D, Vinhas H, Gonçalves RB, Mimoso J. Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes in contemporaneous clinical practice. Hellenic J Cardiol 2023:S1109-9666(23)00222-1. [PMID: 37956770 DOI: 10.1016/j.hjc.2023.11.003] [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: 07/31/2023] [Revised: 10/07/2023] [Accepted: 11/09/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes (NSTE-ACS) during hospitalization is still a matter of contention within the cardiology community. Our aim was to analyze in-hospital and one-year follow-up outcomes of patients with NSTE-ACS pretreated with dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT). METHODS A retrospective study was carried out with NSTE-ACS patients planned to undergo an invasive strategy and were included in the Portuguese Registry of ACS between 2018-2021. A composite primary outcome (in-hospital re-infarction, stroke, heart failure, hemorrhage, death) was compared regarding antiplatelet strategy (DAPT versus SAPT). Secondary outcomes were defined as one-year all-cause mortality and one-year cardiovascular rehospitalization. RESULTS A total of 1469 patients were included, with a mean age of 66±12 years and 73.9% were male. DAPT regime was used in 38.2% and SAPT in 61.8% of patients. NSTE myocardial infarction was the most frequent presentation (88.5%). Revascularization after 24h occurred in 44.8% patients (63% of these after 48h). Enoxaparin was the anticoagulant more frequently used (45.1%). The primary outcome was more frequently observed in the SAPT group (10.4%, p=0.033), mainly driven by more ischemic events. Time until revascularization > 48h and SAPT regime were independent predictors of the primary outcome (OR 1.66, p=0.036 and OR 2.03, p=0.008, respectively). CONCLUSION NSTE-ACS patients pretreated with SAPT had worse in-hospital outcomes. This difference can be probably explained by a delay in time until revascularization. Pretreatment DAPT strategy and crossover between heparins is still frequently used in clinical practice.
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Affiliation(s)
- Hugo Costa
- Algarve University and Hospital Center, Faro, Algarve, Portugal.
| | | | | | - João Bispo
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | - João Guedes
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | - Pedro Azevedo
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | | | - Hugo Vinhas
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | | | - Jorge Mimoso
- Algarve University and Hospital Center, Faro, Algarve, Portugal
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21
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 397] [Impact Index Per Article: 397.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Gomes DA, Rocha BM, Ferreira J, Paiva MS, Reis Santos R, Santos MR, Cunha G, DE Araújo Gonçalves P, Fevereiro S, Trabulo M, Aguiar C, Sousa-Uva M, Neves J, Mendes M. Pretreatment with a P2Y12 receptor inhibitor and delay to coronary artery bypass surgery in patients with non-ST segment elevation acute coronary syndrome. Minerva Cardiol Angiol 2023; 71:582-589. [PMID: 36475547 DOI: 10.23736/s2724-5683.22.06199-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND 2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS. METHODS Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded. RESULTS The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding. CONCLUSIONS Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.
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Affiliation(s)
- Daniel A Gomes
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal -
| | - Bruno M Rocha
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Jorge Ferreira
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Mariana S Paiva
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Rita Reis Santos
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Marina R Santos
- Department of Cardiology, Hospital Dr. Nélio Mendonça, Funchal, Portugal
| | - Gonçalo Cunha
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Pedro DE Araújo Gonçalves
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Susana Fevereiro
- Department of Hemotherapy, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Marisa Trabulo
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Carlos Aguiar
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Sousa-Uva
- Department of Cardio-Thoracic Surgery, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - José Neves
- Department of Cardio-Thoracic Surgery, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Mendes
- Department of Cardiology, Hospital de Santa Cruz - Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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Gawaz M, Geisler T, Borst O. Current concepts and novel targets for antiplatelet therapy. Nat Rev Cardiol 2023; 20:583-599. [PMID: 37016032 DOI: 10.1038/s41569-023-00854-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/06/2023]
Abstract
Platelets have a crucial role in haemostasis and atherothrombosis. Pharmacological control of platelet hyper-reactivity has become a cornerstone in the prevention of thrombo-ischaemic complications in atherosclerotic diseases. Current antiplatelet therapies substantially improve clinical outcomes in patients with coronary artery disease, but at the cost of increased risk of bleeding. Beyond their role in thrombosis, platelets are known to regulate inflammatory (thrombo-inflammatory) and microcirculatory pathways. Therefore, controlling platelet hyper-reactivity might have implications for both tissue inflammation (myocardial ischaemia) and vascular inflammation (vulnerable plaque formation) to prevent atherosclerosis. In this Review, we summarize the pathophysiological role of platelets in acute myocardial ischaemia, vascular inflammation and atherosclerotic progression. Furthermore, we highlight current clinical concepts of antiplatelet therapy that have contributed to improving patient care and have facilitated more individualized therapy. Finally, we discuss novel therapeutic targets and compounds for antiplatelet therapy that are currently in preclinical development, some of which have a more favourable safety profile than currently approved drugs with regard to bleeding risk. These novel antiplatelet targets might offer new strategies to treat cardiovascular disease.
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Affiliation(s)
- Meinrad Gawaz
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany.
| | - Tobias Geisler
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Oliver Borst
- Department of Cardiology and Angiology, Eberhard Karls University of Tübingen, Tübingen, Germany
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24
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Li Y, Lei M, Zhao Z, Yang Y, An L, Wang J, Sun X, Li C, Xue Z. Effect of pretreatment with a P2Y 12 inhibitor in patients with non-ST-elevation acute coronary syndrome: a systematic review and network meta-analysis. Front Cardiovasc Med 2023; 10:1191777. [PMID: 37539086 PMCID: PMC10394276 DOI: 10.3389/fcvm.2023.1191777] [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: 03/22/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
Background This study aimed to systematically evaluate the effects of different types and doses of pretreatment with P2Y12 inhibitors in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI). Methods Electronic databases were searched for studies comparing pretreatment with different types and doses of P2Y12 inhibitors or comparison between P2Y12 inhibitor pretreatment and nonpretreatment. Electronic databases included the Cochrane Library, PubMed, EMBASE, and Web of Science. Literature was obtained from the establishment of each database until June 2022. The patients included in the study had pretreatment with P2Y12 inhibitors with long-term oral or loading doses, or conventional aspirin treatment (non-pretreatment). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs) during follow-up within 30 days after PCI, which included determining the composite endpoints of cardiac death, myocardial infarction, ischemia-driven revascularization, and stroke. The safety endpoint was a major bleeding event. Results A total of 119,014 patients from 21 studies were enrolled, including 13 RCTs and eight observational studies. A total of six types of interventions were included-nonpretreatment (placebo), clopidogrel pretreatment, ticagrelor pretreatment, prasugrel pretreatment, double loading pretreatment (double loading dose of clopidogrel, ticagrelor, prasugrel) and P2Y12 inhibitors pretreatment (the included studies did not distinguish the types of P2Y12 inhibitors, including clopidogrel, ticagrelor, and prasugrel). The network meta-analysis results showed that compared to patients without pretreatment, patients receiving clopidogrel pretreatment (RR = 0.78, 95% CI:0.66, 0.91, P < 0.05) and double-loading pretreatment (RR = 0.62, 95% CI:0.41, 0.95, P < 0.05) had a lower incidence of MACCEs. There was no statistically significant difference in the incidence of major bleeding events among the six pretreatments (P > 0.05). Conclusions In patients with NSTE-ACS, pretreatment with P2Y12 inhibitors before percutaneous intervention reduced the incidence of recurrent ischemic events without increasing the risk of major bleeding after PCI compared with nonpretreatment. Clopidogrel or double loading dose P2Y12 inhibitors can be considered for the selection of pretreatment drugs.
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25
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Arockiam S, Staniforth B, Kepreotis S, Maznyczka A, Bulluck H. A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice. Int J Mol Sci 2023; 24:11132. [PMID: 37446310 DOI: 10.3390/ijms241311132] [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: 04/13/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient's thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.
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Affiliation(s)
- Sacchin Arockiam
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Brittany Staniforth
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Sacha Kepreotis
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Annette Maznyczka
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
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26
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Occhipinti G, Greco A, Angiolillo DJ, Capodanno D. Gender differences in efficacy and safety of antiplatelet strategies for acute coronary syndromes. Expert Opin Drug Saf 2023; 22:669-683. [PMID: 37542468 DOI: 10.1080/14740338.2023.2245331] [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: 05/28/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) represents the cornerstone of secondary prevention in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention. Despite its undisputed efficacy in reducing thrombotic events, DAPT increases the risk of bleeding, which is associated with higher morbidity and mortality. Novel antiplatelet strategies (i.e. in terms of timing, selection of drugs and their combinations, and modulation strategies) have been tested in randomized trials, suggesting the utility of tailored approaches in selected populations (i.e. patients at high bleeding or ischemic risk). It remains uncertain whether the effect of these strategies is influenced by sex. AREAS COVERED This narrative review provides an overview of available evidence surrounding sex differences in the efficacy and safety of antiplatelet strategies for ACS and analyzes the potential reasons behind these findings. Relevant content was searched for in PubMed. EXPERT OPINION Significant differences between women and men exist in terms of clinical presentation, pharmacotherapies, interventional management, and prognosis of ACS. However, these observations do not appear to be attributed to different pharmacodynamic effects of antiplatelet therapies between women and men. Unfortunately, a critical issue depends on women being often underrepresented in clinical trials, leading to a substantial lack of sex-specific evidence.
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Affiliation(s)
- Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- 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, FL, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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27
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Tantry US, Duhan S, Navarese E, Ramotowski B, Kundan P, Bliden KP, Gurbel P. An update on novel therapies for treating patients with arterial thrombosis. Expert Rev Hematol 2023; 16:593-605. [PMID: 37335893 DOI: 10.1080/17474086.2023.2227788] [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: 01/26/2023] [Accepted: 06/16/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Antithrombotic therapy field is undergoing rapid and significant changes during the past decade. In addition to new therapeutic strategies with existing targets, investigators are exploring the potential use of new targets to address unmet needs to treat patients with arterial diseases. AREAS COVERED We aim to provide an update on and a comprehensive review of the antithrombic agents that are being explored in patients with arterial diseases. We discuss latest developments with respect to upstream antiplatelet agents, and collagen and thrombin pathway inhibitors. We searched PubMed databases for English language articles using keywords: antiplatelet agents, thrombin pathway inhibitors, collagen receptors, arterial disease. EXPERT OPINION Despite implementation of potent P2Y12 inhibitors, there are numerous unmet needs in the treatment of arterial diseases including ceiling effect of currently available antiplatelet agents along with and an elevated risk of bleeding. The latter observations encouraged investigators to explore new targets that can attenuate the generation of platelet-fibrin clot formation and subsequent ischemic event occurrences with minimal effect on bleeding. These targets include collagen receptors on platelets and thrombin generation including FXa, FXIa, and FXIIa. In addition, investigators are studying novel antiplatelet agents/strategies to facilitate upstream therapy in high-risk patients.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Sanchit Duhan
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Eliano Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Bogumil Ramotowski
- Department of Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Parshotam Kundan
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Paul Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Sigal AR, Rivero M, Meza M, Filippa G, Procopio G, Abud CM, Nani S, Odone M, Duronto E, Costabel JP. [Impact of pretreatment with P2Y12 inhibitors in patients with acute coronary syndromes without ST elevation. Analysis of 2 multicenter registries]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:96-101. [PMID: 38046231 PMCID: PMC10688406 DOI: 10.47487/apcyccv.v4i3.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/22/2023] [Indexed: 12/05/2023]
Abstract
Objectives To evaluate the rate of use of antiplatelet pretreatment in patients with non-ST elevated acute coronary syndrome (NSTEACS) and its association with adverse events in two Argentine registries. Materials and methods We retrospectively analyzed two Argentine acute coronary syndrome (ACS) registries from 2017 and 2022. We explored the incidence of pretreatment and the drug used. We evaluated the relationship between this strategy and a composite clinical outcome of in-hospital events: death + myocardial infarction + stent thrombosis + post-MI angina + transient ischemic event/cerebrovascular event, and with bleeding events (BARC 2 or higher). Subsequently, we performed a multivariate analysis by logistic regression with other clinical variables. Results A total of 1297 patients were included; 75.6% were men, 25.6% diabetics, 27.1% smokers, 70.3% hypertensive, and 23.1% had a previous ACS. The mean age was 55.3 years. The mean GRACE score was 113.5, and the CRUSADE was 23.8. 44% of the patients received pretreatment, the majority with clopidogrel (93.5%). Pretreatment was significantly associated with a higher incidence of the composite clinical outcome (10.1% vs. 6.9%) (OR 1,56; IC 95%: 1,06-2,3; p=0,02). Bleeding events were numerically more frequent with pretreatment (8.7% vs. 5.9%) (OR 1,51; IC95%: 0,99 -2,3; p=0,054). In the multivariate analysis, pretreatment was no longer associated with a higher incidence of ischemic outcomes (OR 1,4; IC95%: 0,89-2,3; p=0,13). Conclusion Pretreatment was used in almost half of the patients, mainly with clopidogrel, and did not show a reduction in ischemic events in patients with NSTACS.
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Affiliation(s)
- Alan R Sigal
- Instituto Cardiovascular de Buenos Aires. Buenos Aires, Argentina. Instituto Cardiovascular de Buenos Aires Buenos Aires Argentina
| | - Mirza Rivero
- CEMIC. Buenos Aires, Argentina. CEMIC Buenos Aires Argentina
| | - Mayra Meza
- CEMIC. Buenos Aires, Argentina. CEMIC Buenos Aires Argentina
| | - Gerardo Filippa
- CEMEP. Tierra del Fuego, Argentina. CEMEP Tierra del Fuego Argentina
| | - Gastón Procopio
- Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina. Hospital Universitario Fundación Favaloro Buenos Aires Argentina
| | - Camila M Abud
- Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina. Hospital Universitario Fundación Favaloro Buenos Aires Argentina
| | - Sebastián Nani
- Clínica Olivos. Buenos Aires, Argentina. Clínica Olivos Buenos Aires Argentina
| | - Martín Odone
- Sanatorio San Lucas. Buenos Aires, Argentina. Sanatorio San Lucas Buenos Aires Argentina
| | - Ernesto Duronto
- Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina. Hospital Universitario Fundación Favaloro Buenos Aires Argentina
| | - Juan P Costabel
- Instituto Cardiovascular de Buenos Aires. Buenos Aires, Argentina. Instituto Cardiovascular de Buenos Aires Buenos Aires Argentina
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Zilinyi RS, Stant JA, Sayan OR, Collins MB, Rabbani LE. Twenty Years of an Institutional Chest Pain Pathway: What's Come and What's Yet to Come. Crit Pathw Cardiol 2023; 22:41-44. [PMID: 37220657 DOI: 10.1097/hpc.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level. This chest pain clinical pathway has undergone regular review and updates under a collaborative team of cardiologists, emergency department physicians, cardiac nurse practitioners, and other associated stakeholders in the treatment of patients presenting with chest pain. This review will discuss the key changes that our institutional chest pain algorithm has undergone over the last 2 decades and what the future holds for chest pain algorithms.
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Affiliation(s)
- Robert S Zilinyi
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Jennifer A Stant
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Michael B Collins
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - LeRoy E Rabbani
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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30
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Angiolillo DJ, Erlinge D, Ferreiro JL, Gale CP, Huber K, Musumeci G, Collet JP. European practice patterns for antiplatelet management in NSTE-ACS patients: Results from the REal-world ADoption survey focus on acute antiPlatelet treatment (READAPT) survey. Int J Cardiol 2023:S0167-5273(23)00717-9. [PMID: 37201617 DOI: 10.1016/j.ijcard.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/08/2023] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The 2020 European Society of Cardiology (ESC) guidelines for the diagnosis and management of patients with non-ST elevation-acute coronary syndrome (NSTE-ACS) recommend early invasive coronary angiography in high-risk patients and no routine pre-treatment with oral P2Y12 receptor inhibitor in NSTE-ACS patients prior to defining coronary anatomy. OBJECTIVE To assess the implementation of this recommendation in the real-life setting. METHODS A web-survey in 17 European countries collected physician profiles and their perceptions of the diagnosis, medical and invasive management of NSTE-ACS patients at their hospital. A sample size of at least 1100 responders permitted the estimation of proportions with a precision of at least ±3.0%. RESULTS Among the 3024 targeted participants, 1154 provided valid feedback defined as a 50% response rate of answers to the survey questions. Overall, >60% of the participants declared full implementation of the guidelines at their institution. The time delay from admission to coronary angiography and PCI was reported to be <24 h in over 75% of the hospitals while pre-treatment was intended in >50% of NSTE-ACS patients. Ad-hoc percutaneous coronary intervention (PCI) was performed in >70% of the cases while intravenous platelet inhibition was rarely used (<10%). Between countries differences in practice patterns for antiplatelet management for NSTE-ACS were observed, suggesting heterogeneous implementation of the guidelines. CONCLUSIONS This survey indicates that the implementation of 2020 NSTE-ACS guidelines on early invasive management and pre-treatment is heterogeneous, potentially due by local logistical constraints.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - José Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain; Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL); L'Hospitalet de Llobregat, Spain
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trusts, Leeds, UK
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Sigmund Freud University, Medical School, Vienna, Austria
| | - Giuseppe Musumeci
- Cardiology Division, Ospedale Mauriziano, Torino, Italy; Past President Italian Society of Interventional Cardiology (GISE), Italy
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris 75013, France
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31
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Braumann S, Faber-Zameitat C, Macherey-Meyer S, Tichelbäcker T, Meertens M, Heyne S, Nießen F, Julius Nies R, Nettersheim F, Reuter H, Pfister R, Hellmich M, Burst V, Baldus S, Lee* S, Adler* C. Acute Chest Pain—Diagnostic Accuracy and Pre-Hospital Use of Anticoagulants and Platelet Aggregation Inhibitors. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:317-323. [PMID: 36942800 PMCID: PMC10398374 DOI: 10.3238/arztebl.m2023.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 09/20/2022] [Accepted: 03/07/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Acute chest pain (aCP) can be a symptom of life-threatening diseases such as acute coronary or aortic syndrome, but often has a non-cardiac cause. The recommendations regarding pre-hospital drug treatment of patients with aCP are ambiguous. METHODS A retrospective cohort study was conducted of 822 patients with aCP who were attended by emergency physicians. The cause of aCP was classified as follows: acute coronary syndrome without ST-segment elevation (NSTE-ACS), acute aortic syndrome, hypertensive crisis, cardiac arrhythmias, musculoskeletal, or other. The suspected and discharge diagnoses were compared, and the pre-hospital administration of acetylsalicylic acid (ASA) and unfractionated heparin (UFH) was analyzed. Furthermore, the parameters that improved diagnostic accuracy were investigated. RESULTS The positive predictive value of the diagnosis assigned by the emergency physician (EP diagnosis) was 39.7%. NSTEACS was the most commonly suspected cause of aCP (74.7%), but was confirmed after hospital admission in only 26.3% of patients. ASA was administered in 51%, UFH in 55%, and both substances in 46.4% of cases. A large proportion of patients received anticoagulants in the pre-hospital setting although the discharge diagnosis was not NSTE-ACS: ASA 62.9%, UFH 66.0%, both substances 56.5%. CONCLUSION ASA and UFH are often given to EP-accompanied patients with aCP despite the low accuracy of diagnosis in the pre-hospital setting. Pre-hospital measurement of high-sensitivity troponin T (hs Trop-T) might improve discrimination between NSTE-ACS and other causes of aCP. This is important, as the current guidelines contain no clear recommendations for prehospital drug treatment in NSTE-ACS.
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Affiliation(s)
- Simon Braumann
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Christian Faber-Zameitat
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Sascha Macherey-Meyer
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Tobias Tichelbäcker
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Max Meertens
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Sebastian Heyne
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Franz Nießen
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Richard Julius Nies
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Felix Nettersheim
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Hannes Reuter
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
- Department of Internal Medicine, Evangelical Hospital Cologne-Weyertal
| | - Roman Pfister
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Martin Hellmich
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
- Medical Faculty, University of Cologne, and Institute for Medical Statistics, Cologne University Hospital
| | - Volker Burst
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
- Medical Faculty, University of Cologne, and Clinical Acute and Emergency Medicine Team, Cologne University Hospital
- Medical Faculty, University of Cologne, and Department of Internal Medicine II, Cologne University Hospital
| | - Stephan Baldus
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Samuel Lee*
- * Joint last authors
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
| | - Christoph Adler*
- * Joint last authors
- Medical Faculty, University of Cologne, and Department of Internal Medicine III, Cologne University Hospital
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Fujisaki T, Kuno T, Briasoulis A, Misumida N, Takagi H, Latib A. P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis. Tex Heart Inst J 2023; 50:493517. [PMID: 37302149 DOI: 10.14503/thij-22-7916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated. METHODS Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed. RESULTS This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24). CONCLUSION Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside, and Mount Sinai West, New York, New York
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Marcaccio CL, Patel PB, Rastogi V, Stangenberg L, Liang P, Wyers MC, Jim J, Schneider PA, Schermerhorn ML. Efficacy and safety of single versus dual antiplatelet therapy in carotid artery stenting. J Vasc Surg 2023; 77:1434-1446.e11. [PMID: 36581013 PMCID: PMC10122699 DOI: 10.1016/j.jvs.2022.12.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Current guidelines recommend dual antiplatelet (AP) therapy (DAPT) before carotid artery stenting (CAS); however, the true clinical effect of single AP therapy vs DAPT is unknown. We examined the efficacy and safety of preoperative single AP therapy vs DAPT in patients who had undergone transfemoral CAS (tfCAS) or transcarotid artery revascularization (TCAR). METHODS We identified all patients who had undergone tfCAS or TCAR in the Vascular Quality Initiative database from 2016 to 2021. We stratified the patients by procedure and identified those who had received the following preoperative AP regimens: DAPT (acetylsalicylic acid [ASA] + P2Y12 inhibitor [P2Yi]), no AP therapy, ASA only, ASA + AP loading dose, P2Yi only, and P2Yi + AP loading dose. The AP loading dose was given within 4 hours of CAS. We generated propensity scores for each treatment regimen and assessed in-hospital outcomes using inverse probability weighted log binomial regression, with DAPT as the reference and adjusting for intraoperative protamine use. The primary efficacy outcome was a composite end point of stroke and death, and the primary safety outcome was access-related bleeding. RESULTS Of the 18,570 tfCAS patients, 70% had received DAPT, 5.6% no AP therapy, 10% ASA only, 8.0% ASA + AP loading dose, 4.6% P2Yi only, and 2.9% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 2.2%, 6.8%, 4.1%, 5.1%, 2.4%, and 2.3%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (relative risk [RR], 2.3; 95% confidence interval [CI], 1.7-3.2), ASA only (RR, 1.6; 95% CI, 1.2-2.1), and ASA + AP loading dose (RR, 2.0; 95% CI, 1.5-2.7) but was similar with P2Yi only (RR, 0.99; 95% CI, 0.58-1.7) and P2Yi + AP loading dose (RR, 1.1; 95% CI, 0.49-2.5). Of the 25,459 TCAR patients, 81% had received DAPT, 2.0% no AP therapy, 5.5% ASA only, 3.5% ASA + AP loading dose, 4.9% P2Yi only, and 2.4% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 1.5%, 3.3%, 3.3%, 2.9%, 1.2%, and 1.1%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (RR, 2.0; 95% CI, 1.2-3.3) and ASA only (RR, 2.2; 95% CI, 1.5-3.1), with a trend toward a higher incidence with ASA + AP loading dose (RR, 1.6; 95% CI, 0.99-2.6), and was similar with P2Yi only (RR, 0.98; 95% CI, 0.54-1.8) and P2Yi + AP loading dose (RR, 0.66; 95% CI, 0.27-1.6). No differences were found in the incidence of access-related bleeding between the treatment groups after tfCAS or TCAR. CONCLUSIONS Compared with DAPT, no AP therapy or ASA monotherapy was associated with higher rates of stroke/death after CAS and should be discouraged as unsafe practice. Meanwhile, P2Yi monotherapy was associated with similar rates of stroke/death. No differences were found in the incidence of bleeding complications, and adding an AP loading dose to ASA or P2Yi monotherapy within 4 hours of the procedure did not affect the outcomes. Overall, these findings support the current guidelines recommending DAPT before CAS but also suggest that P2Yi monotherapy might confer thromboembolic benefits similar to those with DAPT. However, an immediate preoperative AP loading dose might not provide additional thromboembolic benefits.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeffrey Jim
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Emilsson OL, Koul S. Reply: Pretreatment with unfractionated heparin in patients undergoing primary PCI: a standard of treatment together with DAPT? EUROINTERVENTION 2023; 18:1473-1474. [PMID: 37092267 PMCID: PMC10111130 DOI: 10.4244/eij-d-22-00867] [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] [Received: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 04/25/2023]
Affiliation(s)
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
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Tscharre M, Gremmel T. Antiplatelet Therapy in Coronary Artery Disease: Now and Then. Semin Thromb Hemost 2023; 49:255-271. [PMID: 36455618 DOI: 10.1055/s-0042-1758821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Cardiovascular disease, particularly coronary artery disease (CAD), remains the leading cause of mortality and morbidity in industrialized countries. Platelet activation and aggregation at the site of endothelial injury play a key role in the processes ultimately resulting in thrombus formation with vessel occlusion and subsequent end-organ damage. Consequently, antiplatelet therapy has become a mainstay in the pharmacological treatment of CAD. Several drug classes have been developed over the last decades and a broad armamentarium of antiplatelet agents is currently available. This review portrays the evolution of antiplatelet therapy, and provides an overview on previous and current antiplatelet drugs and strategies.
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Affiliation(s)
- Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria.,Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria.,Institute of Antithrombotic Therapy in Cardiovascular Disease, Karl Landsteiner Society, St. Pölten, Austria
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Niezgoda P, Ostrowska M, Adamski P, Gajda R, Kubica J. Pretreatment with P2Y 12 Receptor Inhibitors in Acute Coronary Syndromes-Is the Current Standpoint of ESC Experts Sufficiently Supported? J Clin Med 2023; 12:jcm12062374. [PMID: 36983373 PMCID: PMC10054246 DOI: 10.3390/jcm12062374] [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: 12/30/2022] [Revised: 02/22/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Excessive platelet reactivity plays a pivotal role in the pathogenesis of acute myocardial infarction. Today, the vast majority of patients presenting with acute coronary syndromes qualify for invasive treatment strategy and thus require fast and efficient platelet inhibition. Since 2008, in cases of ST-elevation myocardial infarction, the European Society of Cardiology guidelines have recommended pretreatment with a P2Y12 inhibitor. This approach has become the standard of care in the majority of centers worldwide. Nevertheless, the latest guidelines for the management of patients presenting with acute coronary syndrome without persisting ST-elevation preclude routine pretreatment with the P2Y12 receptor inhibitor. Those who oppose pretreatment support their stance with trials failing to prove the benefits of this strategy at the cost of an increased risk of major bleeding, especially in individuals inappropriately diagnosed with an acute coronary syndrome, thus having no indication for platelet inhibition. However, adequate platelet inhibition requires even up to several hours after application of a loading dose of P2Y12 receptor inhibitors. Omission of data from pharmacokinetic and pharmacodynamic studies in the absence of data from clinical studies makes generalization of the pretreatment recommendations difficult to accept. We aimed to review the scientific evidence supporting the current recommendations regarding pretreatment with P2Y12 inhibitors.
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Affiliation(s)
- Piotr Niezgoda
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
| | - Robert Gajda
- Gajda-Med Medical Center, 06-100 Pułtusk, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
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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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O'Malley K, Hwang YJ, Trost J, Feldman L. Things We Do for No Reason™: Routine pretreatment with a P2Y12 receptor inhibitor before invasive coronary angiography for patients with a non-ST elevation acute coronary syndrome. J Hosp Med 2023; 18:177-180. [PMID: 35920593 DOI: 10.1002/jhm.12931] [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] [Received: 05/06/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Kevin O'Malley
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yoseob Joseph Hwang
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Trost
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leonard Feldman
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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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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40
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Azzahhafi J, Broek WWAVD, Chan Pin Yin DRPP, Harmsze AM, van Schaik RHN, Ten Berg JM. The Clinical Implementation of CYP2C19 Genotyping in Patients with an Acute Coronary Syndrome: Insights From the FORCE-ACS Registry. J Cardiovasc Pharmacol Ther 2023; 28:10742484231210704. [PMID: 37899583 DOI: 10.1177/10742484231210704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Guidelines recommend prasugrel or ticagrelor for acute coronary syndrome (ACS) patients. However, these P2Y12 inhibitors increase bleeding risk compared to clopidogrel. Although genotype-guided P2Y12-inhibitor selection has been shown to reduce bleeding risk, data on its clinical implementation is lacking. METHODS The study included ACS patients receiving genotype-guided antiplatelet therapy, utilising either a point-of-care (POC) device or laboratory-based testing. We aimed to collect qualitative and quantitative data on genotyping, eligibility for de-escalation, physician adherence to genotype results, time to de-escalation and cost reduction. RESULTS Of the 1,530 patients included in the ACS registry from 2021 to 2023, 738 ACS patients treated with ticagrelor received a CYP2C19 genotype test. The median turnover time of genotyping was 6.3 hours (interquartile range [IQR], 3.2-16.7), with 82.3% of the genotyping results known within 24 hours after admission. POC genotyping exhibited significantly shorter turnaround times compared to laboratory-based testing (with respective medians of 5.7 vs 47.8 hours; P < .001). Of the genotyped patients, 81.7% were eligible for de-escalation which was carried out within 24 hours in 70.9% and within 48 h in 93.0%. The time to de-escalation was significantly shorter using POC (25.4 hours) compared to laboratory-based testing (58.9 hours; P < .001). Implementing this strategy led to a reduction of €211,150.50 in medication costs. CONCLUSIONS CYP2C19 genotype-guided-de-escalation in an all-comers ACS population is feasible. POC genotyping leads to shorter turnaround times and quicker de-escalation. Time to de-escalation from ticagrelor to clopidogrel in noncarriers was short, with high physician adherence to genotype results.
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Affiliation(s)
- Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Ankie M Harmsze
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, the Netherlands
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Borovac JA, Ferri-Certic J, Miric D, Zanchi J, Lozo M, Bradaric A, Schwarz K, Kwok CS. Revascularization with Coronary Artery Bypass Grafting in Non-ST-elevation Acute Coronary Syndromes: A Snapshot of Randomized Trials and Registries. Arq Bras Cardiol 2022; 120:e20220248. [PMID: 36629603 PMCID: PMC9833314 DOI: 10.36660/abc.20220248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 09/01/2022] [Indexed: 01/09/2023] Open
Affiliation(s)
- Josip Andelo Borovac
- Cardiovascular Diseases DepartmentUniversity Hospital of SplitSplitCroáciaCardiovascular Diseases Department, University Hospital of Split, Split – Croácia
| | - Jerko Ferri-Certic
- Department of CardiologyDubrovnik General HospitalDubrovnikCroáciaDepartment of Cardiology, Dubrovnik General Hospital, Dubrovnik – Croácia
| | - Dino Miric
- Cardiovascular Diseases DepartmentUniversity Hospital of SplitSplitCroáciaCardiovascular Diseases Department, University Hospital of Split, Split – Croácia
| | - Jaksa Zanchi
- Cardiovascular Diseases DepartmentUniversity Hospital of SplitSplitCroáciaCardiovascular Diseases Department, University Hospital of Split, Split – Croácia
| | - Mislav Lozo
- Cardiovascular Diseases DepartmentUniversity Hospital of SplitSplitCroáciaCardiovascular Diseases Department, University Hospital of Split, Split – Croácia
| | - Anteo Bradaric
- Cardiovascular Diseases DepartmentUniversity Hospital of SplitSplitCroáciaCardiovascular Diseases Department, University Hospital of Split, Split – Croácia
| | - Konstantin Schwarz
- Department of Internal Medicine 3University Hospital St. PoltenKarl Landsteiner University of Health SciencesKremsÁustriaDepartment of Internal Medicine 3, University Hospital St. Polten, Karl Landsteiner University of Health Sciences, Krems – Áustria
| | - Chun Shing Kwok
- Royal Stoke University HospitalStoke-on-TrentReino UnidoRoyal Stoke University Hospital, Stoke-on-Trent – Reino Unido
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Lahu S, Scalamogna M, Ndrepepa G, Menichelli M, Valina C, Hemetsberger R, Witzenbichler B, Bernlochner I, Joner M, Xhepa E, Hapfelmeier A, Kufner S, Sager HB, Mayer K, Kessler T, Laugwitz K, Richardt G, Schunkert H, Neumann F, Kastrati A, Cassese S. Prior Myocardial Infarction and Treatment Effect of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndromes - A Post-hoc Analysis of the ISAR-REACT 5 Trial. J Am Heart Assoc 2022; 11:e027257. [PMID: 36515247 PMCID: PMC9798807 DOI: 10.1161/jaha.122.027257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndrome and prior myocardial infarction (MI) remain unstudied. We aimed to assess the treatment effect of ticagrelor versus prasugrel according to prior MI status in patients with ACS. Methods and Results Patients with acute coronary syndrome planned for an invasive strategy and randomized to ticagrelor or prasugrel in the ISAR-REACT (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) 5 trial were included. The primary end point was the composite of 1-year all-cause death, MI, or stroke; the secondary safety end point was the composite of 1-year Bleeding Academic Research Consortium type 3 to 5 bleeding. The study included 4015 patients (prior MI=631 patients; no prior MI=3384 patients). As compared with patients without prior MI, the primary end point occurred more frequently in patients with prior MI (12.6% versus 7.2%; hazard ratio [HR], 1.78 [95% CI, 1.38-2.29]); the secondary safety end point appears to differ little between patients with and without prior MI (5.8% versus 5.7%, respectively; HR, 1.02 [95% CI, 0.71-1.45]). With regard to the primary end point, ticagrelor versus prasugrel was associated with an HR of 1.62 (95% CI, 1.03-2.55) in patients with prior MI and an HR of 1.28 (95% CI, 0.99-1.65) in patients without prior MI (Pint=0.37). With regard to the secondary safety end point, ticagrelor versus prasugrel was associated with an HR of 1.28 (95% CI, 0.56-2.91) in patients with prior MI and an HR of 1.13 (95% CI, 0.82-1.55) in patients without prior MI (Pint=0.79). Conclusions Patients with acute coronary syndrome and prior MI are at higher risk for recurrent ischemic but not bleeding events. Prasugrel is superior to ticagrelor in reducing the risk of ischemic events without a tradeoff in bleeding regardless of prior MI status. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany
| | - Maria Scalamogna
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,Department of Advanced Biomedical SciencesUniversity of Naples Federico IINaplesItaly
| | - Gjin Ndrepepa
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany
| | | | - Christian Valina
- Department of Cardiology and Angiology IIUniversity Heart Center Freiburg ‐ Bad Krozingen, Standort Bad KrozingenBad KrozingenGermany
| | - Rayyan Hemetsberger
- Heart Center Bad Segeberg, Segeberger Kliniken GmbH, Bad SegebergBad SegebergGermany
| | | | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany,Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der IsarMunichGermany
| | - Michael Joner
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany
| | - Erion Xhepa
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany
| | - Alexander Hapfelmeier
- Technical University of Munich, School of MedicineInstitute of AI and Informatics in MedicineMunichGermany,Technical University of Munich, School of MedicineInstitute of General Practice and Health Services ResearchMunichGermany
| | - Sebastian Kufner
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany
| | - Hendrik B. Sager
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany
| | - Katharina Mayer
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany
| | - Thorsten Kessler
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany
| | - Karl‐Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany,Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der IsarMunichGermany
| | - Gert Richardt
- Heart Center Bad Segeberg, Segeberger Kliniken GmbH, Bad SegebergBad SegebergGermany
| | - Heribert Schunkert
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany
| | - Franz‐Josef Neumann
- Department of Cardiology and Angiology IIUniversity Heart Center Freiburg ‐ Bad Krozingen, Standort Bad KrozingenBad KrozingenGermany
| | - Adnan Kastrati
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart AllianceMunichGermany
| | - Salvatore Cassese
- Klinik für Herz‐ und Kreislauferkrankungen, Deutsches Herzzentrum MünchenTechnische Universität MünchenMunichGermany
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Leick J, Grottke O, Oezkur M, Mangner N, Sanna T, Al Rashid F, Vandenbriele C. What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention? Eur Heart J Suppl 2022; 24:J17-J24. [PMCID: PMC9731207 DOI: 10.1093/eurheartjsupp/suac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Interest in the use of percutaneous left ventricular assist devices (p-LVADs) for patients undergoing high-risk percutaneous coronary intervention (PCI) is growing rapidly. The Impella™ (Abiomed Inc.) is a catheter-based continuous micro-axial flow pump that preserves haemodynamic support during high-risk PCI. Anticoagulation is required to counteract the activation of the coagulation system by the patient’s procoagulant state and the foreign-body surface of the pump. Excessive anticoagulation and the effect of dual antiplatelet therapy (DAPT) increase the risk of bleeding. Inadequate anticoagulation leads to thrombus formation and device dysfunction. The precarious balance between bleeding and thrombosis in patients with p-LVAD support is often the primary reason that patients’ outcomes are jeopardized. In this chapter, we will discuss anticoagulation strategies and anticoagulant management in the setting of protected PCI. This includes anticoagulant therapy with unfractionated heparin, direct thrombin inhibitors, DAPT, purge blockage prevention by bicarbonate-based purge solution, and monitoring by activated clotting time, partial thromboplastin time, as well as anti-factor Xa levels. Here, we provide a standardized approach to the management of peri-interventional anticoagulation in patients undergoing protected PCI.
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Affiliation(s)
- Jürgen Leick
- Corresponding author. Tel: +49 651208981911, Fax: 00496512082786,
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital Mainz, 55131 Mainz, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universitaet Dresden, Dresden, Germany
| | - Tommaso Sanna
- Institute of Cardiology, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fadi Al Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, 45147 Essen, Germany
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44
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Management of Acute Coronary Syndrome. Emerg Med Clin North Am 2022; 40:693-706. [DOI: 10.1016/j.emc.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Marquis-Gravel G, Robert-Halabi M, Bainey KR, Tanguay JF, Mehta SR. The Evolution of Antiplatelet Therapy After Percutaneous Coronary Interventions: A 40-Year Journey. Can J Cardiol 2022; 38:S79-S88. [PMID: 35231553 DOI: 10.1016/j.cjca.2022.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/05/2022] [Accepted: 02/22/2022] [Indexed: 12/30/2022] Open
Abstract
Antiplatelet therapy has a critical role to play in the successful management of patients undergoing percutaneous coronary intervention (PCI). Over the past 40 years, a multitude of participants worldwide have been enrolled in trials evaluating the impact of antiplatelet agents on clinical outcomes. The use of aspirin in unstable angina in the Canadian Aspirin trial was key to establishing the benefit of aspirin in acute coronary syndrome. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial demonstrated that the P2Y12 inhibitor clopidogrel, when added to aspirin, reduced major cardiovascular events. While the use of antiplatelet agents in coronary artery disease antedates the introduction of PCI and remains the cornerstone of secondary prevention of atherosclerotic cardiovascular disease, strategies aiming to optimise their best use are still constantly evolving. In this review, the major randomised trials shaping current clinical practice for the use of aspirin and P2Y12 inhibitors in patients undergoing PCI are summarised, with a focus on aspirin-free strategies and on the role of P2Y12 inhibitor treatment before PCI, two major topics of ongoing investigation that are critical to patient care but that are not addressed in current practice guidelines. Multiple questions remain regarding the use of antiplatelet agents after PCI, including the personalisation of dosing, intensity, pharmacologic formulation, and duration of antiplatelet therapy based on individual patient characteristics and the optimal treatment of patients at high bleeding risk.
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Affiliation(s)
| | | | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
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Godtfredsen SJ, Kragholm KH, Leutscher P, Jørgensen SH, Christensen MK, Butt JH, Gislason G, Køber L, Fosbøl EL, Sessa M, Bhatt DL, Torp-Pedersen C, Pareek M. Effectiveness and safety of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a nationwide registry-based study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:697-705. [PMID: 35950769 DOI: 10.1093/ehjacc/zuac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/10/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
AIMS To compare the effectiveness and safety of clopidogrel, ticagrelor, and prasugrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS Nationwide, registry-based study of STEMI patients treated with primary PCI (2011-17) and subsequently with aspirin and a P2Y12 inhibitor. The effectiveness outcome was major adverse cardiovascular events (MACE) defined as a composite of recurrent myocardial infarction, repeat revascularization, stroke, or cardiovascular death at 12 months. The safety outcome was bleeding requiring hospitalization at 12 months. Multivariable logistic regression with average treatment effect modeling was used to calculate absolute and relative risks for outcomes standardized to the distributions of demographic characteristics of all included subjects. We included 10 832 patients; 1 697 were treated with clopidogrel, 7 508 with ticagrelor, and 1,627 with prasugrel. Median ages were 66, 63, and 59 years (P < 0.001). Standardized relative risks of MACE were 0.75 for ticagrelor vs. clopidogrel (95% confidence interval [CI], 0.64-0.83), 0.84 for prasugrel vs. clopidogrel (95% CI, 0.73-0.94), and 1.12 for prasugrel vs. ticagrelor (95% CI, 1.00-1.24). Standardized relative risks of bleeding were 0.77 for ticagrelor vs. clopidogrel (95% CI, 0.59-0.93), 0.89 for prasugrel vs. clopidogrel (95% CI, 0.64-1.15), and 1.17 for prasugrel vs. ticagrelor (95% CI, 0.89-1.45). CONCLUSION Ticagrelor and prasugrel were associated with lower risks of MACE after STEMI than clopidogrel, and ticagrelor was associated with a marginal reduction compared with prasugrel. The risk of bleeding was lower with ticagrelor compared with clopidogrel, but did not significantly differ between ticagrelor and prasugrel.
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Affiliation(s)
- Sissel J Godtfredsen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| | - Peter Leutscher
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Steen Hylgaard Jørgensen
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Martin Kirk Christensen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Jagtvej 160 Building 22, 2100 Copenhagen, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
| | - Christian Torp-Pedersen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
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Current and Future Insights for Optimizing Antithrombotic Therapy to Reduce the Burden of Cardiovascular Ischemic Events in Patients with Acute Coronary Syndrome. J Clin Med 2022; 11:jcm11195605. [PMID: 36233469 PMCID: PMC9573364 DOI: 10.3390/jcm11195605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
The pharmacological treatment strategies for acute coronary syndrome (ACS) in recent years are constantly evolving to develop more potent antithrombotic agents, as reflected by the introduction of more novel P2Y12 receptor inhibitors and anticoagulants to reduce the ischemic risk among ACS patients. Despite the substantial improvements in the current antithrombotic regimen, a noticeable number of ACS patients continue to experience ischemic events. Providing effective ischemic risk reduction while balancing bleeding risk remains a clinical challenge. This updated review discusses the currently approved and widely used antithrombotic agents and explores newer antithrombotic treatment strategies under development for the initial phase of ACS.
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Ideal P2Y12 Inhibitor in Acute Coronary Syndrome: A Review and Current Status. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19158977. [PMID: 35897347 PMCID: PMC9331944 DOI: 10.3390/ijerph19158977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
Dual antiplatelet therapy (DAPT) has remained the cornerstone for management of acute coronary syndrome (ACS) over the years. Clopidogrel has been the quintessential P2Y12 receptor (platelet receptor for Adenosine 5′ diphosphate) inhibitor for the past two decades. With the demonstration of unequivocal superior efficacy of prasugrel/ticagrelor over clopidogrel, guidelines now recommend these agents in priority over clopidogrel in current management of ACS. Cangrelor has revived the interest in injectable antiplatelet therapy too. Albeit the increased efficacy of these newer agents comes at the cost of increased bleeding and this becomes more of a concern when combined with aspirin. Which P2Y12i is superior over another has been intensely debated over last few years after the ISAR-REACT 5 study with inconclusive data. Three novel antiplatelet agents are already in the pipeline for ACS with all of them succeeding in phase II studies. The search for an ideal antiplatelet remains a need of the hour for optimal reduction of ischemic events in ACS.
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Yan L, Zhou Y, Yu Z, Xuan M, Xu B, Peng F. P2Y12 inhibitor pretreatment in patients with nonST-segment elevation acute coronary syndrome: A meta-analysis. Medicine (Baltimore) 2022; 101:e29824. [PMID: 35801776 PMCID: PMC9259160 DOI: 10.1097/md.0000000000029824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The 2020 European Society of Cardiology guidelines do not recommend pretreatment for nonST-segment elevation myocardial infarction (NSTEMI) patients with unclear coronary anatomy, which is inconsistent with our routine preoperative approach to loading P2Y12 receptor inhibitors (e.g., preoperative loading of 300 mg of clopidogrel). OBJECTIVES The purpose of our study was to compare the safety and effectiveness of P2Y12 inhibitors administered before coronary angiography or at least before percutaneous coronary intervention (PCI) with during or after PCI. METHODS Cochrane, PubMed, and Embase databases were searched. The primary effect endpoint and safety endpoint were any-cause death and major bleeding, respectively. Major adverse cardiovascular events, myocardial infarction and revascularization were also analyzed. RESULTS Our search identified 9 trials. P2Y12 inhibitor pretreatment was associated with lower death from any cause (OR 0.62, 95% CI 0.53-0.72, P < 0.00001) without increasing the risk of bleeding (OR 1.02, 95% CI 0.80-1.30, P = 0.89). However, prasugrel or ticagrelor pretreatment was not associated with a lower risk of mortality (OR 0.70, 95% CI 0.31-1.59, P = 0.40) and increased the risk of bleeding (OR 1.67, 95% CI 1.10-2.54, P = 0.02). CONCLUSIONS In summary, clopidogrel pretreatment was associated with significantly lower mortality, major adverse cardiovascular events, myocardial infarction and revascularization with no increase in major bleeding. However, these advantages were not observed with prasugrel or ticagrelor pretreatment.
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Affiliation(s)
- Longhui Yan
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Yan Zhou
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Zhangjie Yu
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Mengmei Xuan
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Buyun Xu
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
- *Correspondence: Fang Peng (e-mail: ), Buyun Xu (e-mail: )
| | - Fang Peng
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
- *Correspondence: Fang Peng (e-mail: ), Buyun Xu (e-mail: )
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50
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Behnes M, Lahu S, Ndrepepa G, Menichelli M, Mayer K, Wöhrle J, Bernlochner I, Gewalt S, Witzenbichler B, Hochholzer W, Sibbing D, Cassese S, Angiolillo DJ, Hemetsberger R, Valina C, Müller A, Kufner S, Hamm CW, Xhepa E, Hapfelmeier A, Sager HB, Joner M, Fusaro M, Richardt G, Laugwitz KL, Neumann FJ, Schunkert H, Schüpke S, Kastrati A, Akin I. Ticagrelor or prasugrel in patients with acute coronary syndrome with off-hour versus on-hour presentation: a subgroup analysis of the ISAR-REACT 5 trial. Clin Res Cardiol 2022; 112:518-528. [PMID: 35789430 PMCID: PMC10050020 DOI: 10.1007/s00392-022-02040-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/09/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To assess the efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndrome (ACS) presenting during off- and on-hours. BACKGROUND The efficacy and safety of ticagrelor versus prasugrel in patients with ACS according to time of hospital presentation remain unknown. METHODS This post hoc analysis of the ISAR-REACT 5 trial included 1565 patients with ACS presenting off-hours and 2453 patients presenting on-hours, randomized to ticagrelor or prasugrel. The primary endpoint was a composite of death, myocardial infarction, or stroke; the safety endpoint was Bleeding Academic Research Consortium (BARC) type 3-5 bleeding, both at 12 months. RESULTS The primary endpoint occurred in 80 patients (10.4%) in the ticagrelor group and 57 patients (7.3%) in the prasugrel group in patients presenting off-hours (hazard ratio [HR] = 1.45; 95% confidence interval [CI] 1.03-2.03; P = 0.033), and 104 patients (8.5%) in the ticagrelor group and 80 patients (6.7%) in the prasugrel group in patients presenting on-hours (HR = 1.29 [0.97-1.73]; P = 0.085), without significant treatment arm-by-presentation time interaction (Pint = 0.62). BARC type 3 to 5 bleeding occurred in 35 patients (5.1%) in the ticagrelor group and 37 patients (5.3%) in the prasugrel group (P = 0.84) in patients presenting off-hours, and 60 patients (5.9%) in the ticagrelor group and 43 patients (4.6%) in the prasugrel group in patients presenting on-hours (P = 0.17). CONCLUSIONS In patients with ACS planned to undergo an invasive treatment strategy, time of presentation (off-hours vs. on-hours) does not interact significantly with the relative efficacy and safety of ticagrelor vs. prasugrel. CLINICAL TRIAL REGISTRATION NCT01944800.
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Affiliation(s)
- Michael Behnes
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Shqipdona Lahu
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Gjin Ndrepepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Katharina Mayer
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Jochen Wöhrle
- Department of Cardiology, Medical Campus Lake Constance, Friedrichshafen, Germany
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.,Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Senta Gewalt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.,Klinikum der Universität München, Ludwig-Maximilians-University, Cardiology, Munich, Germany
| | - Salvatore Cassese
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Arne Müller
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Christian W Hamm
- Heart Center, Campus Kerckhoff of Justus-Liebig-University, Giessen, Germany
| | - Erion Xhepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alexander Hapfelmeier
- School of Medicine, Institute of AI and Informatics in Medicine, Technical University of Munich, Munich, Germany.,School of Medicine, Institute of General Practice and Health Services Research, Technical University of Munich, Munich, Germany
| | - Hendrik B Sager
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Massimiliano Fusaro
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.,Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.
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