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Ndrepepa G, Cassese S, Xhepa E, Joner M, Sager HB, Kufner S, Laugwitz KL, Schunkert H, Kastrati A. Aspirin loading and coronary no-reflow after percutaneous coronary intervention in patients with acute myocardial infarction. Eur J Clin Invest 2024; 54:e14173. [PMID: 38264959 DOI: 10.1111/eci.14173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND The association of aspirin loading with the risk of coronary no-reflow (CNR) after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) has not been investigated. We assessed the association of aspirin loading before PCI with CNR in patients with AMI. MATERIALS AND METHODS This study included 3100 patients with AMI undergoing PCI. Of them, 2812 patients received aspirin loading (a single oral [or chewed] or intravenous dose of 150-300 mg) and 288 patients did not receive aspirin loading before PCI. The primary endpoint was CNR, defined as Thrombolysis in Myocardial Infarction blood flow grade of <3 after the PCI. RESULTS CNR occurred in 130 patients: 127 patients in the group with aspirin loading and 3 patients in the group without aspirin loading before PCI (4.5% vs. 1.0%; odds ratio [OR] = 4.50, 95% confidence interval, [1.42-14.21], p = 0.005). After adjustment, the association between aspirin loading and CNR was significant (adjusted OR = 4.49 [1.56-12.92]; p < 0.001). There was no aspirin loading-by-P2Y12 inhibitor (ticagrelor or prasugrel) interaction (pint = 0.465) or aspirin loading-by-chronic aspirin therapy on admission (pint = 0.977) interaction with respect to the occurrence of CNR after PCI. Chronic low-dose aspirin therapy on admission was not independently associated with higher risk of CNR after PCI (adjusted OR = 1.06 [0.65-1.72]; p = 0.824). CONCLUSION In patients with AMI undergoing PCI, aspirin loading before the PCI procedure at the guideline-recommended doses was associated with higher odds of developing CNR. However, due to the limited number of events, the findings should be considered as hypothesis generating.
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Affiliation(s)
- Gjin Ndrepepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, 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
| | - 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
| | - Sebastian Kufner
- 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
| | - 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
| | - 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
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Triska J, Haddadin F, Madanat L, Jabri A, Daher M, Birnbaum Y, Jneid H. The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2024; 38:605-619. [PMID: 35829979 DOI: 10.1007/s10557-022-07367-3] [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] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
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Affiliation(s)
- Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Faris Haddadin
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Luai Madanat
- Department of Medicine, William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marilyne Daher
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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3
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Herron GC, Bates ER. Review of the Ticagrelor Trials Evidence Base. J Am Heart Assoc 2024:e031606. [PMID: 38804216 DOI: 10.1161/jaha.123.031606] [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] [Indexed: 05/29/2024]
Abstract
Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.
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Affiliation(s)
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine University of Michigan Ann Arbor MI USA
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Aytekin A, Scalamogna M, Coughlan JJ, Lahu S, Ndrepepa G, Menichelli M, Mayer K, Wöhrle J, Bernlochner I, Witzenbichler B, Hochholzer W, Sibbing D, Angiolillo DJ, Hemetsberger R, Tölg R, Valina C, Müller A, Kufner S, Liebetrau C, Xhepa E, Hapfelmeier A, Sager HB, Joner M, Richardt G, Laugwitz KL, Neumann FJ, Schunkert H, Schüpke S, Kastrati A, Cassese S. Incidence and pattern of urgent revascularization in acute coronary syndromes treated with ticagrelor or prasugrel. Clin Res Cardiol 2024:10.1007/s00392-024-02454-x. [PMID: 38740722 DOI: 10.1007/s00392-024-02454-x] [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: 02/26/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The ISAR-REACT 5 trial compared the efficacy and safety of ticagrelor and prasugrel in patients with ACS managed invasively. The present study sought to investigate the impact of ticagrelor and prasugrel on the incidence and pattern of urgent revascularization in acute coronary syndromes (ACS) patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS This post-hoc analysis of the ISAR-REACT 5 trial included all ACS patients who underwent PCI. The primary endpoint for this analysis was the incidence of urgent revascularization at 12-month follow-up. Secondary outcome was the pattern of urgent revascularization procedures (namely, urgent target vessel/non-target vessel revascularization - TVR/NTVR). Among 3,377 ACS patients who underwent PCI, 1,676 were assigned to ticagrelor and 1,701 to prasugrel before PCI. After 12 months, the incidence of urgent revascularization was higher among patients assigned to ticagrelor as compared to prasugrel (6.8% vs. 5.2%; hazard ratio [HR] = 1.32, 95% confidence interval [CI] 1.00-1.75; p = 0.051), mostly attributable to significantly more urgent NTVR in the ticagrelor group (3.8% vs. 2.4%; HR = 1.62 [1.09-2.41]; p = 0.017). The risk of urgent TVR did not differ between treatment groups (3.3% vs. 3.0%; HR = 1.13 [0.77-1.65]; p = 0.546). CONCLUSIONS In ACS patients treated with PCI, the cumulative rate of urgent revascularizations after 12 months is higher with ticagrelor compared to prasugrel, due to a significant increase in urgent revascularizations involving remote coronary vessels.
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Affiliation(s)
- Alp Aytekin
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | - Maria Scalamogna
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | - J J Coughlan
- Cardiovascular Research Institute, Mater Private Network, Dublin, Ireland
| | - Shqipdona Lahu
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | - Gjin Ndrepepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | | | - Katharina Mayer
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | - Jochen Wöhrle
- Department of Cardiology, Medical Campus Lake Constance, Friedrichshafen, Germany
| | - Isabell Bernlochner
- Klinik Und Poliklinik Für Innere Medizin I, Klinikum Rechts Der Isar, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Intensive Care Medicine, Klinikum Würzburg Mitte, Würzburg, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Klinik der Universität München, Ludwig-Maximilians-University, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Rayyan Hemetsberger
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Ralph Tölg
- Department of Cardiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Christian Valina
- Department of Cardiology and Angiology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arne Müller
- Klinik Und Poliklinik Für Innere Medizin I, Klinikum Rechts Der Isar, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | - Christoph Liebetrau
- Heart Center, Campus Kerckhoff of Justus-Liebig-University, Giessen, Germany
| | - Erion Xhepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of AI and Informatics in Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
| | - Hendrik B Sager
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Gert Richardt
- Department of Cardiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Karl-Ludwig Laugwitz
- Klinik Und Poliklinik Für Innere Medizin I, Klinikum Rechts Der Isar, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Franz Josef Neumann
- Department of Cardiology and Angiology, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Salvatore Cassese
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse, 36, Munich, Germany.
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Mohamed MO, Kontopantelis E, Alasnag M, Abid L, Banerjee A, Sharp ASP, Bourantas C, Sirker A, Curzen N, Mamas MA. Impact of Society Guidelines on Trends in Use of Newer P2Y 12 Inhibitors for Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. J Am Heart Assoc 2024; 13:e034414. [PMID: 38700032 DOI: 10.1161/jaha.124.034414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Over the past decade, major society guidelines have recommended the use of newer P2Y12 inhibitors over clopidogrel for those undergoing percutaneous coronary intervention for acute coronary syndrome. It is unclear what impact these recommendations had on clinical practice. METHODS AND RESULTS All percutaneous coronary intervention procedures (n=534 210) for acute coronary syndrome in England and Wales (April 1, 2010, to March 31, 2022) were retrospectively analyzed, stratified by choice of preprocedural P2Y12 inhibitor (clopidogrel, ticagrelor, and prasugrel). Multivariable logistic regression models were used to examine odds ratios of receipt of ticagrelor and prasugrel (versus clopidogrel) over time, and predictors of their receipt. Overall, there was a significant increase in receipt of newer P2Y12 inhibitors from 2010 to 2020 (2022 versus 2010: ticagrelor odds ratio, 8.12 [95% CI, 7.67-8.60]; prasugrel odds ratio, 6.14 [95% CI, 5.53-6.81]), more so in ST-segment-elevation myocardial infarction than non-ST-segment-elevation acute coronary syndrome indication. The most significant increase in odds of receipt of prasugrel was observed between 2020 and 2022 (P<0.001), following a decline/plateau in its use in earlier years (2011-2019). In contrast, the odds of receipt of ticagrelor significantly increased in earlier years (2012-2017, Ptrend<0.001), after which the trend was stable (Ptrend=0.093). CONCLUSIONS Over a 13-year-period, there has been a significant increase in use of newer P2Y12 inhibitors, although uptake of prasugrel use remained significantly lower than ticagrelor. Earlier society guidelines (pre-2017) were associated with the highest rates of ticagrelor use for non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction cases while the ISAR-REACT 5 (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome) trial and later society guidelines were associated with higher prasugrel use, mainly for ST-segment-elevation myocardial infarction indication.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research Keele University Stoke-on-Trent United Kingdom
- Institute of Health Informatics University College London London United Kingdom
- Barts Heart Centre St. Bartholomew's Hospital London United Kingdom
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre (MAHSC) University of Manchester United Kingdom
| | - Mirvat Alasnag
- Cardiac Center King Fahd Armed Forces Hospital Jeddah Saudi Arabia
| | - Leila Abid
- Hedi Chaker University Hospital Sfax Tunisia
| | - Amitava Banerjee
- Institute of Health Informatics University College London London United Kingdom
- Barts Heart Centre St. Bartholomew's Hospital London United Kingdom
- Department of Cardiology University College London Hospitals NHS Foundation Trust London United Kingdom
| | - Andrew S P Sharp
- Department of Cardiology University Hospitals Wales Cardiff United Kingdom
- Department of Cardiology University of Cardiff United Kingdom
| | - Christos Bourantas
- Barts Heart Centre St. Bartholomew's Hospital London United Kingdom
- Device and Innovation Centre William Harvey Research Institute, Queen Mary University London London United Kingdom
| | - Alex Sirker
- Barts Heart Centre St. Bartholomew's Hospital London United Kingdom
- Department of Cardiology University College London Hospitals NHS Foundation Trust London United Kingdom
| | - Nick Curzen
- Faculty of Medicine University of Southampton United Kingdom
- Department of Cardiology University Hospital Southampton NHS Trust Southampton United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research Keele University Stoke-on-Trent United Kingdom
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Kim SH, Shin S, Choo EH, Choi IJ, Lim S, Moon D, Kim CJ, Park MW, Kim MC, Hwang BH, Lee KY, Choi YS, Kim HY, Yoo KD, Jeon DS, Ahn Y, Chang K. Clinical Impact of Dyspnea after Ticagrelor Treatment and the Effect of Switching to Clopidogrel in Patients with Myocardial Infarction. Thromb Haemost 2024. [PMID: 38574757 DOI: 10.1055/a-2299-4537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Dyspnea is frequent during ticagrelor-based dual antiplatelet therapy (DAPT) for acute myocardial infarction (AMI). However, its clinical characteristics or management strategy remains uncertain. METHODS The study assessed 2,617 AMI patients from the Ticagrelor versus Clopidogrel in Stabilized Patients with AMI (TALOS-AMI) trial. Dyspnea during 1-month ticagrelor-based DAPT and following DAPT strategies with continued ticagrelor or de-escalation to clopidogrel from 1 to 12 months were evaluated for drug adherence, subsequent dyspnea, major adverse cardiovascular events (MACE), and bleeding events. RESULTS Dyspnea was reported by 538 patients (20.6%) during 1 month of ticagrelor-based DAPT. Adherence to allocated DAPT over the study period was lower in the continued ticagrelor arm than the de-escalation to clopidogrel, particularly among the dyspneic population (81.1% vs. 91.5%, p < 0.001). Among ticagrelor-treated patients with dyspnea, those switched to clopidogrel at 1 month had a lower frequency of dyspnea at 3 months (34.3% vs. 51.7%, p < 0.001) and 6 months (25.5% vs. 38.4%, p = 0.002) than those continued with ticagrelor. In patients with dyspnea in their 1-month ticagrelor-based DAPT, de-escalation was not associated with increased MACE (1.3% vs. 3.9%, hazard ratio [HR]: 0.31, 95% confidence interval [CI]: 0.08-1.11, p = 0.07) or clinically relevant bleeding (3.2% vs. 6.2%, HR: 0.51, 95% CI: 0.22-1.19, p = 0.12) at 1 year. CONCLUSION Dyspnea is a common side effect among ticagrelor-based DAPTs in AMI patients. Switching from ticagrelor to clopidogrel after 1 month in AMI patients may provide a reasonable option to alleviate subsequent dyspnea in ticagrelor-relevant dyspneic patients, without increasing the risk of ischemic events (NCT02018055).
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Affiliation(s)
- Sang Hyun Kim
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, The Armed Forces Capital Hospital, Seongnam, Korea
| | - Sanghoon Shin
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Ik Jun Choi
- Division of Cardiology, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
| | - Sungmin Lim
- Division of Cardiology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Donggyu Moon
- Division of Cardiology, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Chan Joon Kim
- Division of Cardiology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Mahn-Won Park
- Division of Cardiology, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Byung-Hee Hwang
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Kwan Yong Lee
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Yun Seok Choi
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
- Division of Cardiology, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Hee-Yeol Kim
- Division of Cardiology, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Ki-Dong Yoo
- Division of Cardiology, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Doo Soo Jeon
- Division of Cardiology, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kiyuk Chang
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
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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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8
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Fischer Q, Pham V, Seret G, Brami P, Picard F, Varenne O. Antiplatelet therapy for treatment of coronary artery disease in older patients. Arch Cardiovasc Dis 2024:S1875-2136(24)00055-X. [PMID: 38658313 DOI: 10.1016/j.acvd.2024.02.008] [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: 11/28/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 04/26/2024]
Abstract
Coronary artery disease in older patients is more frequently diffuse and complex, and is often treated by percutaneous coronary intervention on top of medical therapy. There are currently no specific recommendations for antiplatelet therapy in patients aged≥75 years. Aspirin remains pivotal, and is still indicated as a long-term treatment after percutaneous coronary intervention. In addition, a P2Y12 inhibitor is administered for 6-12 months according to clinical presentation. Age is a minor bleeding risk factor, but because older patients often have several co-morbidities, they are considered as having a high bleeding risk according to different scoring systems. This increased bleeding risk has resulted in different therapeutic strategies for antithrombotic treatment after percutaneous coronary intervention; these include short dual antiplatelet therapy, a switch from potent to less potent antiplatelet therapy or single antiplatelet therapy with a P2Y12 inhibitor instead of aspirin, among others. A patient-centred approach, taking into account health status, functional ability, frailty, cognitive skills, bleeding and ischaemic risks and patient preference, is essential when caring for older adults with coronary artery disease. The present review focuses on the knowledge base, specificities of antiplatelet therapies, a balance between haemorrhagic and ischaemic risk, strategies for antiplatelet therapy and directions for future investigation pertaining to coronary artery disease in older patients.
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Affiliation(s)
- Quentin Fischer
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Vincent Pham
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Gabriel Seret
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Pierre Brami
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Fabien Picard
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Olivier Varenne
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
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9
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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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10
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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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11
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Wu YJ, Wu CC, Huang HY, Wu CY, Huang CC, Wang CC. Low-dose prasugrel versus standard-dose ticagrelor in east Asian patients with acute coronary syndrome. J Thromb Thrombolysis 2024; 57:537-546. [PMID: 38555552 DOI: 10.1007/s11239-024-02965-4] [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] [Accepted: 03/08/2024] [Indexed: 04/02/2024]
Abstract
Low-dose prasugrel demonstrated a similar effectiveness profile to clopidogrel in East Asian ACS patients, but its comparison with another new-generation potent P2Y12 inhibitor, ticagrelor, remains unclear. To compare the effectiveness and safety of low-dose prasugrel against those of standard-dose ticagrelor in East Asian patients with ACS. This retrospective cohort study used Taiwan's National Health and Welfare Database. This study included ACS patients who underwent percutaneous coronary intervention and, at discharge between January 1, 2018 and December 31, 2020, were prescribed with low-dose prasugrel plus aspirin or standard-dose ticagrelor plus aspirin. Stabilized inverse probability of treatment weighting was used to balance the covariates across these two groups. The primary effectiveness outcome was a composite of acute myocardial infarction, ischemic stroke, and cardiovascular death; the secondary effectiveness outcome was each of the individual components of the primary outcome, transient ischemic attack, and repeat revascularization. The primary safety outcome was a composite of intracranial hemorrhage and gastrointestinal bleeding, and the two secondary safety outcomes were intracranial hemorrhage and gastrointestinal bleeding. A total of 24,807 patients were included in this study. Among them, 1,493 were low-dose prasugrel users and 23,314 were standard-dose ticagrelor users. No significant differences were found in primary effectiveness [HR: 0.97 (0.74-1.28)] or primary safety outcomes [HR: 1.22 (0.73-2.01)] between the two study groups. For East Asian patients with ACS, low-dose prasugrel provides comparable effectiveness without increasing bleeding risk compared to standard-dose ticagrelor. Low-dose prasugrel may be an appropriate alternative for East Asian populations.
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Affiliation(s)
- Yee-Jen Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan
| | - Hsin-Yi Huang
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan
| | - Chi-Yun Wu
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chuan Wang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan.
- School of Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan.
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Room 203, No. 33 Linsen S. Rd., Zhongzheng Dist, Taipei, 10050, Taiwan.
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12
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Huang CL, Tsao TP, Yin WH, Huang WB, Jen HL, Lin CC, Chang CY, Hsu CH. Comprehensive comparative efficacy and safety of potent P2Y 12 inhibitors in patients undergoing coronary intervention: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2024; 51:101359. [PMID: 38371311 PMCID: PMC10869917 DOI: 10.1016/j.ijcha.2024.101359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
Potent P2Y12 receptor antagonists have been used widely for patients undergoing percutaneous coronary intervention with different results. Benefits from different regimens various between trials. Randomized controlled trials (RCTs) have restrictive inclusion and exclusion criteria; thus, they may limit the generalizability of the findings to a broader population. This study was aimed to comprehensively investigate the outcomes of potent P2Y12 inhibitors in patients undergoing PCI, including RCTs and real-world evidence (RWE) studies. Multiple electronic databases were systemically reviewed and searched on compared potent P2Y12 inhibitors with clopidogrel. The primary efficacy end point was composite ischemic cardiovascular event and primary safety endpoint was major bleeding. Overall estimates of proportions and incidence rates with 95 % confidence intervals (CI) were calculated using fixed-effects models. Total 24 studies (140,986 patients) underwent coronary intervention were included in this meta-analysis, including 18 RCTs and 6 large cohort studies with propensity score matching. The potent P2Y12 inhibitors including cangrelor, prasugrel, and ticagrelor, significantly decreased the risk of composite adverse cardiovascular ischemic events (95 % CI 0.89-0.96, p < 0.001), but increased major bleeding (95 % CI 1.15-1.33, p < 0.001) or any bleeding (95 % CI 1.21-1.33, p < 0.001) compared with Clopidogrel. This meta-analysis merges RCTs and RWE studies and comprehensively evidences newer potent P2Y12 inhibitors are significantly more effective than clopidogrel in reduction of composite adverse thrombotic events, but the incidence of major or any bleeding was higher compared with clopidogrel.
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Affiliation(s)
- Chien-Lung Huang
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Tien-Ping Tsao
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
- National Defense Medical Centre, Taipei, Taiwan, ROC
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
- Deputy Dean, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Wen-Bin Huang
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Hsu-Lung Jen
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chang-Chyi Lin
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chung-Yi Chang
- Cardiovascular surgeon, Division of Cardiovascular Surgery, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Ching-Hwa Hsu
- School of Nursing, College of Medicine, Chang Gung University, Taiwan, ROC
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13
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Cohen M, Sohal S. Editorial: Bivalirudin versus unfractionated heparin in acute myocardial infarction: Why are we still debating? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:62-63. [PMID: 37980264 DOI: 10.1016/j.carrev.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Marc Cohen
- Section of Cardiovascular Medicine, Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ 07112, United States of America.
| | - Sumit Sohal
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
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14
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Ray A, Najmi A, Khandelwal G, Jhaj R, Sadasivam B. Comparative effectiveness and safety of prasugrel and ticagrelor in patients of acute coronary syndrome undergoing percutaneous transluminal coronary angioplasty: A propensity score-matched analysis. Indian Heart J 2024:S0019-4832(24)00039-7. [PMID: 38485052 DOI: 10.1016/j.ihj.2024.03.001] [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: 06/11/2023] [Revised: 02/02/2024] [Accepted: 03/11/2024] [Indexed: 03/18/2024] Open
Abstract
Evidence on comparative effectiveness and safety of prasugrel and ticagrelor post-percutaneous transluminal coronary angioplasty is scarce in Indian population. In a 1:1 propensity score-matched cohort with 71 individuals in each group, the incidence of a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization was not significantly different in prasugrel and ticagrelor group (7.04% vs 9.86%; absolute difference, 2.8%; HR, 0.65; 95% CI, 0.21-2.1; p = 0.49). There was no significant difference in bleeding (5.63% vs 9.86%; absolute difference, -4.20%; 95% CI, -13.0%-4.5%) and dyspnea (7.04% vs 12.7%; absolute difference, -5.60%; 95% CI, -15.4%-4.1%).
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Affiliation(s)
- Avik Ray
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Ahmad Najmi
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India.
| | - Gaurav Khandelwal
- Department of Cardiology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India.
| | - Ratinder Jhaj
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India.
| | - Balakrishnan Sadasivam
- Department of Pharmacology, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India.
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15
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Nohria R, Antono B. Acute Coronary Syndrome. Prim Care 2024; 51:53-64. [PMID: 38278573 DOI: 10.1016/j.pop.2023.07.003] [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] [Indexed: 01/28/2024]
Abstract
One percent of primary care visits are due to chest pain. It is critical for the primary care physician to have a high index of suspicion for acute coronary syndrome and understand the management of this important condition. This article reviews the outpatient evaluation and management of chest pain and summarizes the key points of inpatient evaluation and treatment of acute coronary syndrome.
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Affiliation(s)
- Raman Nohria
- Department of Family Medicine and Community Health, Duke University School of Medicine, 2100 Erwin Road, Durham, NC 27705, USA.
| | - Brian Antono
- Department of Family Medicine and Community Health, Duke University School of Medicine, 2100 Erwin Road, Durham, NC 27705, USA
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16
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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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17
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Agrawal A, Kumar A, Majid M, Badwan O, Arockiam AD, El Dahdah J, Syed AB, Schleicher M, Reed GW, Cremer PC, Griffin BP, Menon V, Wang TKM. Optimal antiplatelet strategy following coronary artery bypass grafting: a meta-analysis. Heart 2024; 110:323-330. [PMID: 37648436 DOI: 10.1136/heartjnl-2023-323097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/18/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE Coronary artery bypass grafting (CABG) is an established revascularisation strategy for multivessel and left main coronary artery disease. Although aspirin is routinely recommended for patients with CABG, the optimal antiplatelet regimen after CABG remains unclear. We evaluated the efficacies and risks of different antiplatelet regimens (dual (DAPT) versus single (SAPT), and dual with clopidogrel (DAPT-C) versus dual with ticagrelor or prasugrel (DAPT-T/P)) after CABG. METHODS We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and performed a comprehensive literature search using PubMed, Ovid Medline, Ovid Embase and Cochrane Central Register of Controlled Trials. Data were extracted and pooled using random-effects models and Review Manager (V.5.4). RESULTS Among the 2970 article abstracts screened, 215 full-text articles were reviewed and 38 studies totaling 77 447 CABG patients were included for analyses. DAPT compared with SAPT was associated with significantly lower all-cause mortality (OR 0.65 with 95% CI 0.50 to 0.86; p=0.002), cardiovascular mortality (OR 0.53, 95% CI 0.33 to 0.84; p=0.008), and major adverse cardiac and cerebrovascular events (MACCE) (OR 0.68, 95% CI 0.51 to 0.91; p=0.01), but higher rates of major (OR 1.30, 95% CI 1.08 to 1.56; p=0.007) and minor bleeding (OR 1.87, 95% CI 1.28 to 2.74; p=0.001) after CABG. DAPT-T/P compared with DAPT-C was associated with significantly lower all-cause (OR 0.43, 95% CI 0.29 to 0.65; p≤0.0001) and cardiovascular mortality (OR 0.44, 95% CI 0.24 to 0.80; p=0.008), and no differences on other cardiovascular or bleeding outcomes after CABG. CONCLUSION In patients with CABG, DAPT compared with SAPT and DAPT-T/P compared with DAPT-C were associated with reduction in all-cause and cardiovascular mortality, especially in patients with acute coronary syndrome. Additionally, DAPT was associated with reduction in MACCE, but higher rates of major and minor bleeding. An individualised approach to choosing antiplatelet regimen is necessary for patients with CABG based on ischaemic and bleeding risks.
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Affiliation(s)
- Ankit Agrawal
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ashwin Kumar
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Muhammad Majid
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Osamah Badwan
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Joseph El Dahdah
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alveena B Syed
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mary Schleicher
- Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tom Kai Ming Wang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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18
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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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19
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Landi A, Aboyans V, Angiolillo DJ, Atar D, Capodanno D, Fox KAA, Halvorsen S, James S, Jüni P, Leonardi S, Mehran R, Montalescot G, Navarese EP, Niebauer J, Oliva A, Piccolo R, Price S, Storey RF, Völler H, Vranckx P, Windecker S, Valgimigli M. Antithrombotic therapy in patients with acute coronary syndrome: similarities and differences between a European expert consensus document and the 2023 European Society of Cardiology guidelines. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:173-180. [PMID: 38170562 DOI: 10.1093/ehjacc/zuad158] [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: 10/26/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024]
Abstract
Antithrombotic therapy represents the cornerstone of the pharmacological treatment in patients with acute coronary syndrome (ACS). The optimal combination and duration of antithrombotic therapy is still matter of debate requiring a critical assessment of patient comorbidities, clinical presentation, revascularization modality, and/or optimization of medical treatment. The 2023 European Society of Cardiology (ESC) guidelines for the management of patients with ACS encompassing both patients with and without ST segment elevation ACS have been recently published. Shortly before, a European expert consensus task force produced guidance for clinicians on the management of antithrombotic therapy in patients with ACS as well as chronic coronary syndrome. The scope of this manuscript is to provide a critical appraisal of differences and similarities between the European consensus paper and the latest ESC recommendations on oral antithrombotic regimens in ACS patients.
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Affiliation(s)
- Antonio Landi
- Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Tesserete, 48. CH-6900, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King Ave, 87042, Limoges, France
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Dan Atar
- Oslo University Hospital Ulleval, Department of Cardiology, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Sigrun Halvorsen
- Institute of Clinical Medicine, University of Oslo, Blindern, P.O. Box 1078, N-0316, Oslo, Norway
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Stefan James
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sergio Leonardi
- University of Pavia and Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, NewYork, USA
| | - Gilles Montalescot
- ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Eliano Pio Navarese
- Clinical Experimental Cardiology, Department of Clinical Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Angelo Oliva
- Department of Biomedical Sciences, Humanitas University, 20090 Pieve Emanuele-Milan, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Susanna Price
- Royal Brompton Hospital, National Heart and Lung Institute, Imperial College, London, UK
| | - Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Heinz Völler
- Department of Rehabilitation Medicine, Faculty of Health Science Brandenburg, University of Potsdam, Potsdam, Germany
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Ente Ospedaliero Cantonale (EOC), Cardiocentro Ticino Institute, Tesserete, 48. CH-6900, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- University of Bern, Bern, Switzerland
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20
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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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21
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Buske M, Feistritzer HJ, Jobs A, Thiele H. [Management of acute coronary syndrome : ESC guidelines 2023]. Herz 2024; 49:5-14. [PMID: 38032511 DOI: 10.1007/s00059-023-05222-1] [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] [Accepted: 10/26/2023] [Indexed: 12/01/2023]
Abstract
The new guidelines of the European Society of Cardiology (ESC) on the management of acute coronary syndrome (ACS) in 2023 encompass updates for both the guidelines pertaining to ST elevation myocardial infarction (STEMI) and acute coronary syndrome without ST segment elevation (NSTE-ACS). The previously separated guidelines from 2017 and 2020 were therefore revised and summarized. These guidelines address various topics, including diagnostics, acute management, antithrombotic treatment, out-of-hospital cardiac arrest, cardiogenic shock, invasive strategies, and long-term treatment. The notable updates compared to earlier guidelines address the recommendation regarding the timing of invasive diagnostics in NSTE-ACS (Non-ST elevation acute coronary syndrome), the procedure of revascularization in multivessel coronary artery disease and alternative regimens for antithrombotic treatment in patients with a high risk of bleeding.
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Affiliation(s)
- Maria Buske
- Herzzentrum Leipzig - Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - Hans-Josef Feistritzer
- Herzzentrum Leipzig - Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - Alexander Jobs
- Herzzentrum Leipzig - Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland
| | - Holger Thiele
- Herzzentrum Leipzig - Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland.
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22
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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [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] [Indexed: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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23
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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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24
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Kanic V, Kompara G. Clopidogrel, ticagrelor, prasugrel or an alternation of two P2Y12 in patients with acute myocardial infarction with cardiogenic shock. Front Cardiovasc Med 2024; 10:1266127. [PMID: 38235289 PMCID: PMC10792002 DOI: 10.3389/fcvm.2023.1266127] [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: 07/24/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024] Open
Abstract
Background Data are lacking on the effects of the alternation of P2Y12 receptor antagonists (P2Y12) on bleeding and outcome in patients with myocardial infarction (MI) with cardiogenic shock (CS). We compared the effects of different P2Y12 and alternation of P2Y12 (combination) on bleeding and outcome in patients with MI and CS. Methods Data from 247 patients divided into four groups: clopidogrel, ticagrelor, prasugrel, and the combination group, were analyzed. The association between P2Y12 and bleeding as well as 30-day and one-year mortality was examined. Results The highest bleeding rate was observed in patients in the combination group, followed by the clopidogrel, ticagrelor, and prasugrel groups [12(50%) patients, 22(28.2%), 21(18.3%) and 4(13.3%), respectively; p = 0.003]. Bleeding occurred with a similar frequency in the combination and clopidogrel groups (p = 0.081), but more frequently than in the ticagrelor and prasugrel groups (p = 0.002 and p = 0.006, respectively). Bleeding rates were similar in patients receiving P2Y12 alone (p = 0.13). Compared to clopidogrel, both ticagrelor and prasugrel had a lower bleeding risk (aOR: 0.40; 95% CI: 0.18-0.92; p = 0.032 and aOR: 0.20; 95% CI: 0.05-0.85; p = 0.029, respectively) and the combination had a similar bleeding risk (aOR: 2.31; 95% CI: 0.71-7.48; p = 0.16). The ticagrelor and prasugrel groups had more than an 80% and 90% lower bleeding risk than the combination group (aOR: 0.17; 95% CI: 0.06-0.55; p = 0.003 and aOR: 0.09; 95% CI: 0.02-0.44; p = 0.003, respectively). The unadjusted 30-day and one-year mortality were highest in the clopidogrel group, followed by the ticagrelor, prasugrel, and combination groups (44(56.4%) and 55(70.5%) patients died in the clopidogrel group, 53(46.1%) and 56(48.7%) in the ticagrelor group, 12(40%) and 14(46.7%) patients died in the prasugrel, and 6(25%) and 9(37.5%) patients died in the combination group; p = 0.045 and p < 0.0001. After adjustment for confounders, the P2Y12 groups were not independently associated with either 30-day (p = 0.23) or one-year (p = 0.17) mortality risk. Conclusion Our results suggest that the choice of P2Y12 was not associated with treatment outcome. The combination of P2Y12 increased bleeding risk compared with ticagrelor and prasugrel and was comparable to clopidogrel in patients with MI and CS. However, these higher bleeding rates did not result in worse treatment outcomes.
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Affiliation(s)
- Vojko Kanic
- Division of Internal Medicine, Department of Cardiology and Angiology, University Medical Center Maribor, Maribor, Slovenia
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25
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Zhou S, Li W, Xiang Q, Wang Z, Zhang H, Mu G, Liu Z, Cui Y. Optimal anti-platelet therapy for older patients with acute coronary syndrome: a network meta-analysis of randomized trials comprising 59,284 older patients. J Thromb Thrombolysis 2024; 57:143-154. [PMID: 37548902 PMCID: PMC10830599 DOI: 10.1007/s11239-023-02875-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
The aim of this study was to identify the optimal anti-platelet therapy in older acute coronary syndrome (ACS) patients with a mean age ≥ 60 years by comparing the efficacy and safety of different anti-platelet therapies. The selection of antiplatelet therapy in older patients with ACS is a clinical challenge. Numerous evidences indicate that the de-escalation of dual anti-platelet therapy (DAPT) or P2Y12 inhibitor monotherapy may reduce bleeding risk without increasing thrombotic events. However, there is a lack of systematic reviews and optimal strategy analysis regarding older ACS patients. Randomized controlled trials (RCTs) of anti-platelet therapy in older ACS patients were identified. Major adverse cardiovascular events (MACE) were the primary outcome. Secondary outcomes included all death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and trial-defined major bleeding. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on posterior probability. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. A total of 12 RCTs including 59,284 older ACS patients treated with five anti-platelet strategies were included. Ticagrelor monotherapy after 3 months DAPT was comparable to the other strategies (OR 0.73; 95% CI 0.32-1.6) in terms of MACE risk. Additionally, P score analysis and SUCRA Bayesian analysis showed that it was the most beneficial treatment for all deaths, cardiovascular death and revascularization. For safety, although there was no significant difference in direct comparisons, both SUCRA Bayesian (0.806) and P score (0.519) analysis suggested that ticagrelor monotherapy was the safest strategy. The current evidence demonstrated that ticagrelor monotherapy after 3 months DAPT may be a promising approach for achieving a more favorable balance between risk and benefit for older ACS patients, with a relatively low bleeding risk and without an increased risk of MACE events. Moreover, it remains the preferred option for clinical outcomes such as all death, CV death and revascularization. Further high-quality and long-term studies are required to validate anti-platelet therapies among older ACS patients.
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Affiliation(s)
- Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Wenhui Li
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
- School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
- Institute of Clinical Pharmacology, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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26
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Xia X, Chen S, Cao C, Ye Y, Shen Y. New Score Models for Predicting Bleeding and Ischemic of Ticagrelor Therapy in Patients with Diabetes Mellitus. Clin Appl Thromb Hemost 2024; 30:10760296241254107. [PMID: 38780348 PMCID: PMC11119327 DOI: 10.1177/10760296241254107] [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: 02/22/2024] [Revised: 04/10/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Ticagrelor is an antiplatelet drug, and its use increases the risk of bleeding. Coronary artery disease is significantly influenced by the widespread occurrence of diabetes mellitus. In order to decrease the incidence of clinical adverse events, a novel bleeding and thrombosis score is developed in this research. METHODS We conducted a retrospective analysis of patient data from two medical centers who were diagnosed with diabetes mellitus and treated with ticagrelor. We gathered information on every patient from the electronic database of the hospital and follow-up. The collected data were statistically analyzed to obtain risk factors for bleeding and ischemic events. RESULTS A total of 851 patients with diabetes mellitus who have been administered ticagrelor are included in our investigation. A total of 76 patients have bleeding events and 80 patients have ischemic events. The analysis of multiple variables indicates that characteristics like the age of >65, having a previous occurrence of bleeding, experiencing anemia, using aspirin, and taking atorvastatin are linked to a higher likelihood of bleeding. Additionally, the age of >65, smoking, having a history of blood clots, and having a BMI ≥ 30 are found to increase the risk of ischemia. CONCLUSION The A4B score established in this study was better than the HAS-BLED score,and the same is true for the ABST score to the CHA2DS-VASc score. This new risk assessment model can potentially detect patients who are at high risk for bleeding and ischemic events. For high-risk patients, the dose of ticagrelor can be adjusted appropriately or the medication can be adjusted.(2023-09-11, ChiCTR2300075627).
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Affiliation(s)
- Xiaotong Xia
- Department of Pharmacy, Zhongshan Hospital (Xiamen), Fudan University, Fujian Xiamen, China
| | - Shu Chen
- Department of Pharmacy, Zhongshan Hospital (Xiamen), Fudan University, Fujian Xiamen, China
| | - Chang Cao
- Department of Pharmacy, Zhongshan Hospital (Xiamen), Fudan University, Fujian Xiamen, China
| | - YanRong Ye
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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27
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Godtfredsen SJ, Kragholm KH, Kristensen AMD, Bekfani T, Sørensen R, Sessa M, Torp-Pedersen C, Bhatt DL, Pareek M. Ticagrelor or prasugrel vs. clopidogrel in patients with atrial fibrillation undergoing percutaneous coronary intervention for myocardial infarction. EUROPEAN HEART JOURNAL OPEN 2024; 4:oead134. [PMID: 38174346 PMCID: PMC10763543 DOI: 10.1093/ehjopen/oead134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/09/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
Aims The efficacy and safety of ticagrelor or prasugrel vs. clopidogrel in patients with atrial fibrillation (AF) on oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI) have not been established. Methods and results This was a nationwide cohort study of patients on OAC for AF who underwent PCI for MI from 2011 through 2019 and were prescribed a P2Y12 inhibitor at discharge. The primary efficacy outcome was major adverse cardiovascular events (MACE), defined as a composite of death from any cause, stroke, recurrent MI, or repeat revascularization. The primary safety outcome was cerebral, gastrointestinal, or urogenital bleeding requiring hospitalization. Absolute and relative risks for outcomes at 1 year were calculated through multivariable logistic regression with average treatment effect modelling. Outcomes were standardized for the individual components of the CHA2DS2-VASc and HAS-BLED scores as well as type of OAC, aspirin, and proton pump inhibitor use. We included 2259 patients of whom 1918 (84.9%) were prescribed clopidogrel and 341 (15.1%) ticagrelor or prasugrel. The standardized risk of MACE was significantly lower in the ticagrelor or prasugrel group compared with the clopidogrel group (standardized absolute risk, 16.3% vs. 19.4%; relative risk, 0.84, 95% confidence interval, 0.70-0.98; P = 0.02), while the risk of bleeding did not differ (standardized absolute risk, 5.5% vs. 5.1%; relative risk, 1.07, 95% confidence interval, 0.73-1.41; P = 0.69). Conclusion In patients with AF on OAC who underwent PCI for MI, treatment with ticagrelor or prasugrel vs. clopidogrel was associated with reduced ischaemic risk, without a concomitantly increased bleeding risk.
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Affiliation(s)
| | | | | | - Tarek Bekfani
- Department of Cardiology, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Germany
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital—North Zealand Hospital, Hillerød, Denmark
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Cardiology, Copenhagen University Hospital—Herlev and Gentofte, Gentofte Hospitalsvej 8, 3. TH, 2900 Hellerup, Denmark
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28
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Varian FL, Parker WAE, Fotheringham J, Storey RF. Treatment inequity in antiplatelet therapy for ischaemic heart disease in patients with advanced chronic kidney disease: releasing the evidence vacuum. Platelets 2023; 34:2154330. [DOI: 10.1080/09537104.2022.2154330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Frances L. Varian
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
| | - William A. E. Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK and
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29
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Goto H, Saito Y, Matsumoto T, Sato T, Yamashita D, Suzuki S, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. Differential Impact of Clinical Factors for Predicting High Platelet Reactivity on Clinical Outcomes in Acute Myocardial Infarction Patients Treated With Clopidogrel and Prasugrel. J Atheroscler Thromb 2023; 30:1791-1802. [PMID: 37316266 DOI: 10.5551/jat.64217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
AIMS Several scoring systems, including the ABCD-GENE and HHD-GENE scores incorporating clinical and genetic factors, have been developed to identify patients likely to have high platelet reactivity on P2Y12 inhibitors, leading to increased risks of ischemic events. However, genetic testing is not widely available in daily practice. We aimed to evaluate the differential impact of clinical factors in the scores on ischemic outcomes in patients treated with clopidogrel and prasugrel. METHODS This bi-center registry included 789 patients with acute myocardial infarction (MI) undergoing percutaneous coronary intervention and treated with either clopidogrel or prasugrel at discharge. The relations of the number of clinical factors included in the ABCD-GENE (age ≥ 75 years, body mass index >30 kg/m2, chronic kidney disease, and diabetes) and HHD-GENE (hypertension, hemodialysis, and diabetes) scores to the primary endpoint of major cardiovascular events after discharge, a composite of death, recurrent MI, and ischemic stroke, were evaluated. RESULTS The number of clinical factors in the ABCD-GENE score was not predictive of ischemic outcomes after discharge in patients treated with clopidogrel and/or prasugrel, while the increase in the number of clinical factors of the HHD-GENE score was associated with an increased risk of the primary endpoint in a stepwise manner in patients on a P2Y12 inhibitor. CONCLUSIONS Clinical factors listed in the HHD-GENE score may help stratify ischemic risks in patients with acute MI treated with clopidogrel and prasugrel, whereas risk stratification without genetic testing in patients treated with clopidogrel may be challenging.
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Affiliation(s)
- Hiroki Goto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | | | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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30
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Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. Am J Med 2023; 136:1147-1159. [PMID: 37380060 DOI: 10.1016/j.amjmed.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
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Affiliation(s)
- Jitae A Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Mahboob Alam
- Texas Heart Institute and Baylor College of Medicine, Houston
| | - Salim S Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Andrew House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, Ont, Canada
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31
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De Luca L, Gragnano F, Calabrò P, Huber K. Balancing Benefits and Risks of Oral Antiplatelet Strategies in patients With Coronary Artery Diseases: An Evolving Issue. Curr Probl Cardiol 2023; 48:102025. [PMID: 37553063 DOI: 10.1016/j.cpcardiol.2023.102025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Identifying the most appropriate antiplatelet therapy for each patient to prevent ischemic events while minimizing the risk of bleeding is an integral part of the short- and long-term management of patients with coronary artery disease (CAD). This review aims to summarize the available evidence on the contemporary use of P2Y12 inhibitors in CAD patients, focusing on strategies aimed at providing adequate ischemic protection while preventing bleeding risk through dual antiplatelet therapy (DAPT) modulation. Randomized trials and observational studies have been reviewed to determine the most appropriate antiplatelet treatment for CAD patients with different risk profiles. Both ischemic and bleeding events have a significant prognostic impact and should be carefully considered in clinical decision-making. Current guidelines recommend the use of third-generation PY2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel, as a part of DAPT, in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Newer P2Y12 inhibitors have a more rapid onset of action and less interindividual variability in platelet inhibition than clopidogrel but are associated with an increased risk of bleeding that may limit their benefit. Importantly, the anti-ischemic benefit of ticagrelor and prasugrel is mainly observed in the first weeks after ACS, whereas clopidogrel seems to provide the best balance between ischemic protection and bleeding as long-term maintenance therapy. These concepts support DAPT modulation after the acute phase, by de-escalating from full-dose to low-dose newer P2Y12 inhibitors, by switching to clopidogrel, or by early withdrawing aspirin to maximize both the efficacy and safety of antiplatelet therapy in patients with CAD.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, and Sigmund Freud University, Medical Faculty, Vienna, Austria
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32
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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose 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
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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33
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Luo T, Yuan J, Qiu L, Liu D, Jian X, Hu P, Yan P, Wang Q, Yan H. Real-Word Effectiveness of Early Start-Up and Short-Term Use of PCSK9 Inhibitor in the Treatment of Acute Coronary Syndrome in China. Am J Cardiol 2023; 207:137-139. [PMID: 37738783 DOI: 10.1016/j.amjcard.2023.08.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Ting Luo
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Jing Yuan
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Lingzhi Qiu
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Daoquan Liu
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Xun Jian
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Ping Hu
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Pengfei Yan
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Qing Wang
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China
| | - Hua Yan
- Department of Cardiology, Wuhan Asia Heart Hospital Affiliated to Wuhan University of Science and Technology, Wuhan, China.
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34
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Shah RP, Shafiq A, Hamza M, Maniya MT, Duhan S, Keisham B, Patel B, Alamzaib SM, Yashi K, Uppal D, Sattar Y, Tiwari D, Paul TK, AlJaroudi W, Alraies MC. Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 207:206-214. [PMID: 37751668 DOI: 10.1016/j.amjcard.2023.08.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Limited data comparing prasugrel and ticagrelor in acute coronary syndrome are available. Online databases, including MEDLINE and Cochrane Central, were queried to compare these drugs. The primary outcomes of this meta-analysis are myocardial infarction (MI), all-cause mortality, cardiovascular mortality, noncardiovascular mortality, stent thrombosis, and stroke. The secondary outcome is major bleeding. A total of 9 studies, including 94,590 patients (prasugrel group = 32,759; ticagrelor group = 61,831), were included in this meta-analysis. The overall mean age was 62.73 years, whereas the mean age for the ticagrelor and prasugrel groups was 63.80 and 61.65 years, respectively. Prasugrel is equally effective as compared with ticagrelor in preventing MI. There was no difference between the 2 groups regarding all-cause mortality, stent thrombosis, stroke, or major bleeding. In patients with acute coronary syndrome, prasugrel is equally effective when compared with ticagrelor in preventing MI.
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Affiliation(s)
- Rajendra P Shah
- Department of Cardiology, University of Florida/Malcom Randall Veterans Affairs Medical Center, Florida, USA
| | - Aimen Shafiq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammad Hamza
- Department of Medicine, Albany Medical Center, Albany, New York, USA
| | | | - Sanchit Duhan
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Bijeta Keisham
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Bansari Patel
- Department of Medicine, West Virginia University, West Virginia, USA
| | | | - Kanica Yashi
- Department of Medicine, Bassett Healthcare, New York, USA
| | - Dipan Uppal
- Department of Cardiology, Cleveland Clinic Florida, Florida, USA
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Dinesh Tiwari
- Department of Dermatology, Mayo Institute of Medical Sciences, Uttar Pradesh, India
| | - Timir K Paul
- Department of Cardiology, University of Tennessee Health Sciences Center, Nashville, Tennessee, USA
| | - Wael AlJaroudi
- Division of Cardiology, Medical College of Georgia at Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - M Chadi Alraies
- Department of Cardiology, Cardiovascular Institute, Detroit Medical Center, Detroit, Michigan, USA.
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35
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Ndrepepa G, Cassese S, Xhepa E, Joner M, Sager HB, Kufner S, Laugwitz KL, Schunkert H, Kastrati A. Coronary no-reflow and adverse events in patients with acute myocardial infarction after percutaneous coronary intervention with current drug-eluting stents and third-generation P2Y 12 inhibitors. Clin Res Cardiol 2023:10.1007/s00392-023-02340-y. [PMID: 37962571 DOI: 10.1007/s00392-023-02340-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/06/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The frequency and prognostic value of coronary no-reflow (CNR) was investigated in studies that have used an outdated reperfusion therapy in terms of stent technology and antithrombotic drugs. We assessed the association of CNR with adverse outcomes in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and newer antithrombotic drugs, ticagrelor or prasugrel. METHODS This study included 3100 patients with AMI who underwent PCI with current DES and third-generation P2Y12 inhibitors. CNR was defined as Thrombolysis in Myocardial Infarction (TIMI) blood flow grade ≤ 2 at the end of PCI. The primary end point was 1-year incidence of net adverse clinical and cerebral events-a composite end point of death of any cause, myocardial infarction, stroke or major bleeding. RESULTS CNR was diagnosed in 130 patients (4.2%). The primary end point occurred in 28 patients in the CNR group and 354 patients in the reflow group (cumulative incidence 23.2% and 12.8%; adjusted hazard ratio = 1.53, 95% confidence interval 1.01-2.33; P = 0.049). The 1-year incidences of death or myocardial infarction (14.6% vs. 7.6%; P = 0.003), myocardial infarction (8.8% vs. 3.9%; P = 0.007) and major bleeding (10.9% vs. 5.6%; P = 0.008) were significantly higher in patients with CNR than patients with reflow. The risk of adverse events in patients with CNR was highest within the first 30 days after PCI. CONCLUSION In patients with AMI undergoing PCI with current DES and third generation P2Y12 receptor inhibitors, CNR was associated with a higher risk of adverse outcomes at 1 year.
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Affiliation(s)
- Gjin Ndrepepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany.
| | - Salvatore Cassese
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany
| | - Erion Xhepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany
| | - Michael Joner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hendrik B Sager
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Sebastian Kufner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, 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
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636, 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, Lazarettstrasse 36, 80636, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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van der Sangen NMR, Küçük IT, Sivanesan S, Appelman Y, Ten Berg JM, Verburg A, Azzahhafi J, Arkenbout EK, Kikkert WJ, Pisters R, Jukema JW, Arslan F, van 't Hof A, Ilhan M, Hoebers LP, van der Schaaf RJ, Damman P, Woudstra P, van de Hoef TP, Bax M, Anthonio RL, Polad J, Adriaenssens T, Dewilde W, Zivelonghi C, Laanmets P, Majas R, Dijkgraaf MGW, Claessen BEPM, Henriques JPS. Less bleeding by omitting aspirin in non-ST-segment elevation acute coronary syndrome patients: Rationale and design of the LEGACY study. Am Heart J 2023; 265:114-120. [PMID: 37517430 DOI: 10.1016/j.ahj.2023.07.011] [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: 05/26/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Early aspirin withdrawal, also known as P2Y12-inhibitor monotherapy, following percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) can reduce bleeding without a trade-off in efficacy. Still the average daily bleeding risk is highest during the first months and it remains unclear if aspirin can be omitted immediately following PCI. METHODS The LEGACY study is an open-label, multicenter randomized controlled trial evaluating the safety and efficacy of immediate P2Y12-inhibitor monotherapy versus dual antiplatelet therapy (DAPT) for 12 months in 3,090 patients. Patients are randomized immediately following successful PCI for NSTE-ACS to 75-100 mg aspirin once daily versus no aspirin. The primary hypothesis is that immediately omitting aspirin is superior to DAPT with respect to major or minor bleeding defined as Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, while maintaining noninferiority for the composite of all-cause mortality, myocardial infarction and stroke compared to DAPT. CONCLUSIONS The LEGACY study is the first randomized study that is specifically designed to evaluate the impact of immediately omitting aspirin, and thus treating patients with P2Y12-inhibitor monotherapy, as compared to DAPT for 12 months on bleeding and ischemic events within 12 months following PCI for NSTE-ACS.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Shabiga Sivanesan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands
| | - Ashley Verburg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E Karin Arkenbout
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fatih Arslan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnoud van 't Hof
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mustafa Ilhan
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Loes P Hoebers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pier Woudstra
- Department of Cardiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Matthijs Bax
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Rutger L Anthonio
- Department of Cardiology, Treant Zorggroep, Scheper Hospital, Emmen, The Netherlands
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Ziekenhuis, Hertogenbosch, The Netherlands
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Willem Dewilde
- Department of Cardiology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Carlo Zivelonghi
- Department of Cardiology, HartCentrum, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Peep Laanmets
- Department of Cardiology, North Estonia Medical Center Foundation, Tallinn, Estonia
| | - Risko Majas
- Department of Cardiology, North Estonia Medical Center Foundation, Tallinn, Estonia
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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Bikdeli B, Erlinge D, Valgimigli M, Kastrati A, Han Y, Steg PG, Stables RH, Mehran R, James SK, Frigoli E, Goldstein P, Li Y, Shahzad A, Schüpke S, Mehdipoor G, Chen S, Redfors B, Crowley A, Zhou Z, Stone GW. Bivalirudin Versus Heparin During PCI in NSTEMI: Individual Patient Data Meta-Analysis of Large Randomized Trials. Circulation 2023; 148:1207-1219. [PMID: 37746717 DOI: 10.1161/circulationaha.123.063946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The benefit:risk profile of bivalirudin versus heparin anticoagulation in patients with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) is uncertain. Study-level meta-analyses lack granularity to provide conclusive answers. We sought to compare the outcomes of bivalirudin and heparin in patients with non-ST-segment-elevation myocardial infarction undergoing PCI. METHODS We performed an individual patient data meta-analysis of patients with non-ST-segment-elevation myocardial infarction in all 5 trials that randomized ≥1000 patients with any myocardial infarction undergoing PCI to bivalirudin versus heparin (MATRIX [Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox], VALIDATE-SWEDEHEART [Bivalirudin Versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial], ISAR-REACT 4 [Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 4], ACUITY [Acute Catheterization and Urgent Intervention Triage Strategy], and BRIGHT [Bivalirudin in Acute Myocardial Infarction vs Heparin and GPI Plus Heparin Trial]). The primary effectiveness and safety end points were 30-day all-cause mortality and serious bleeding. RESULTS A total of 12 155 patients were randomized: 6040 to bivalirudin (52.3% with a post-PCI bivalirudin infusion), and 6115 to heparin (53.2% with planned glycoprotein IIb/IIIa inhibitor use). Thirty-day mortality was not significantly different between bivalirudin and heparin (1.2% versus 1.1%; adjusted odds ratio, 1.24 [95% CI, 0.86-1.79]; P=0.25). Cardiac mortality, reinfarction, and stent thrombosis rates were also not significantly different. Bivalirudin reduced serious bleeding (both access site-related and non-access site-related) compared with heparin (3.3% versus 5.5%; adjusted odds ratio, 0.59; 95% CI, 0.48-0.72; P<0.0001). Outcomes were consistent regardless of use of a post-PCI bivalirudin infusion or routine lycoprotein IIb/IIIa inhibitor use with heparin and during 1-year follow-up. CONCLUSIONS In patients with non-ST-segment-elevation myocardial infarction undergoing PCI, procedural anticoagulation with bivalirudin and heparin did not result in significantly different rates of mortality or ischemic events, including stent thrombosis and reinfarction. Bivalirudin reduced serious bleeding compared with heparin arising both from the access site and nonaccess sites.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale-New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT (B.B.)
| | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, French Alliance for Cardiovascular Trials, L'Institut national de la santé et de la recherche médicale U-1148, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France (P.G.S.)
- Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Rod H Stables
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | | | - Enrico Frigoli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | | | - Yi Li
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Adeel Shahzad
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Ghazaleh Mehdipoor
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY (G.M.)
| | - Shmuel Chen
- Weill-Cornell Cornell Medical Center/ New York-Presbyterian Hospital, New York, NY (S.C.)
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | | | - Zhipeng Zhou
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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Saito T, Fujisaki T, Aikawa T, Kampaktsis PN, Malik A, Briasoulis A, Takagi H, Wiley J, Slipczuk L, Kuno T. Strategy of dual antiplatelet therapy for patients with ST-elevation myocardial infarction and non-ST-elevation acute coronary syndromes: A systematic review and network meta-analysis. Int J Cardiol 2023; 389:131157. [PMID: 37433404 DOI: 10.1016/j.ijcard.2023.131157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/06/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Various durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown. METHODS PubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y12 inhibitors, short-term DAPT (≤6 months) followed by potent P2Y12 inhibitors or aspirin, unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events. RESULTS Twenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y12 inhibitors (HR:0.57; 95% CI:0.34-0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47-0.90), standard DAPT using potent P2Y12 inhibitors (HR:0.62; 95% CI:0.50-0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55-0.98) without increased risk of MACE. CONCLUSION Unguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.
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Affiliation(s)
- Tetsuya Saito
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadao Aikawa
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Polydoros N Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York City, NY, United States of America
| | - Aaqib Malik
- Department of Cardiology, Westchester Medical Center, NY, United States of America
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart failure and Transplantation, University of Iowa, IA, United States of America
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, LA, United States of America
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, United States of America
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, NY, United States of America; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, NY, United States of America.
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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40
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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: 368] [Impact Index Per Article: 368.0] [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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Harm T, Rath D, Kreisselmeier KP, Baas L, Prang C, Gekeler S, Schröder S, Gawaz MP, Geisler T, Müller II, Müller KAL. Thrombus architecture is influenced by the antiplatelet loading treatment in patients with acute myocardial infarction. Thromb Res 2023; 230:45-54. [PMID: 37634310 DOI: 10.1016/j.thromres.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Intracoronary thrombus formation is a main cause of acute myocardial infarction triggered by platelet activation. However, there are no data on the impact of different treatment strategies with antiplatelet agents before percutaneous coronary intervention (PCI) on histological characteristics of thrombus formation. OBJECTIVE In this study, we investigate the impact of preinterventional administration of the P2Y12-inhibitors clopidogrel and prasugrel on thrombus composition, highlighting significant changes associated with the antiplatelet pre-treatment. METHODS We prospectively enrolled 104 consecutive patients with ST-segment elevation myocardial infarction (STEMI) undergoing immediate PCI and thrombus aspiration by immunohistochemical staining along with RNA-sequencing employing Nanostring analysis. Fifty-two patients were treated with either prasugrel loading (60 mg) or clopidogrel loading (600 mg) prior to PCI, respectively. RESULTS In Patients with STEMI, intracoronary thrombus architecture was significantly altered between patients pre-treated with prasugrel when compared to clopidogrel. Fibrin content of thrombi was significantly decreased (41.8 % versus 66.7 %, p = 0.009) after pre-treatment with prasugrel compared to clopidogrel. Furthermore, levels of MPO positive cells in intracoronary thrombi were significantly decreased in patients with prasugrel pre-treatment (90.5 versus 201.1, p = 0.014) indicating an association of antiplatelet pre-treatment and the inflammatory responses during thrombus formation. Most strikingly, we observed significant differences among both pre-treatment groups regarding altered RNA expression and signaling pathways of thrombo-inflammatory processes within the thrombotic material, which were independently associated with antiplatelet strategies. CONCLUSIONS Our study elucidates the impact of antiplatelet pre-treatment on thrombus remodeling and architecture, thereby lowering the risk of recurrent adverse cardiovascular events in prasugrel-treated patients.
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Affiliation(s)
- Tobias Harm
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Klaus-Peter Kreisselmeier
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Livia Baas
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Carolin Prang
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Sarah Gekeler
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Stephen Schröder
- Department of Cardiology and Angiology, Klinik am Eichert, Eichertstraße 3, 73035 Göppingen, Germany
| | - Meinrad Paul Gawaz
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany.
| | - Iris Irmgard Müller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Karin Anne Lydia Müller
- Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls University Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
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D'Ascenzo F, DE Filippo O, Angelini F, Piroli F, DE Lio G, Bocchino PP, Baldetti L, Melillo F, Chieffo A, Saglietto A, Omedè P, Montefusco A, Conrotto F, de Ferrari GM. Duration and kind of dual antiplatelet therapy for acute coronary syndrome patients: a network meta-analysis. Minerva Cardiol Angiol 2023; 71:494-503. [PMID: 35332750 DOI: 10.23736/s2724-5683.22.06038-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION For acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI), the choice of the duration and kind of dual antiplatelet therapy (DAPT) offering the most accurate balance between ischemic and bleeding risk remains unknown. EVIDENCE ACQUISITION A network meta-analysis was performed including all Randomized Controlled Trials (RCTs) comparing different DAPT regimens and duration in ACS patients undergoing PCI. Trial-defined MACE and major bleedings were the primary endpoints. Stroke, stent thrombosis (ST), all-cause and cardiovascular death, myocardial infarction (MI) represented secondary endpoints. EVIDENCE SYNTHESIS 13 RCTs encompassing 46145 patients were included. Mean age was 62 (61-64) years old, 42% being admitted with STEMI, 33% with NSTEMI and 25% with UA. The competitive arms were: clopidogrel and aspirin for 12 months (6 arms/18183 patients), clopidogrel and aspirin for 6 months (4/3329), clopidogrel and aspirin >12 months (3/2238), ticagrelor and aspirin for 12 months (6/12942) and prasugrel and aspirin for 12 months (3/9453). Trial-defined MACE and major bleedings, stroke and death were similar among the different arms. DAPT with prasugrel and aspirin for 12 months reduced MI compared to aspirin and clopidogrel for 12 months (OR 0.71, 95% CI: 0.54.0.94) and reduced the risk of ST compared to ticagrelor (OR 0.66, 95% CI: 0.49-0.90). Both prasugrel and ticagrelor reduced ST as compared to clopidogrel and aspirin for 12 months. CONCLUSIONS Different DAPT strategies yield similar risk of MACE, major bleeding, death and stroke in ACS patients. Prasugrel and aspirin for 12 months proved to be the most effective strategy regarding ST and MI.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Ovidio DE Filippo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy -
| | - Francesco Piroli
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giulia DE Lio
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pier P Bocchino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - Francesco Melillo
- Cardiac Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - Alaide Chieffo
- Unit of Interventional Cardiology, Department of Cardiology and Cardiothoracic Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Saglietto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Antonio Montefusco
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gaetano M de Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
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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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Bershtein LL, Boldueva SA, Kochanov IN, Lunina MD, Naiden TV, Evdokimov DS, Tandelov BM, Podmetin PS, Zbyshevskaya EV, Gumerova VE, Savinova EB, Piltakyan VH, Sayganov SA. Variability of Measurement and Feasibility of Assessing Changes in Brachiocepahlic Atherosclerotic Plaque After Acute Coronary Syndrome. KARDIOLOGIIA 2023; 63:20-28. [PMID: 37815136 DOI: 10.18087/cardio.2023.9.n2460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/02/2023] [Indexed: 10/11/2023]
Abstract
Aim Analysis of inter- and intra-study variability of changes in the atherosclerotic plaque (ASP) total height and total area, the main quantitative indexes that were planned to be used in the present study for assessment of the atherosclerotic load of carotid arteries.Material and methods The incidence of recurrent cardiovascular complications (CVC) within 1 year after acute coronary syndrome (ACS) ranges from 7-9 % (in studies) to 34 % (in clinical practice). This indicates insufficient efficacy of traditional approaches to secondary prevention of coronary heart disease. We proposed a study to test a hypothesis that the dynamics of ASP parameters in carotid and subclavian regions can serve as an alternative criterion for the adequacy of secondary prevention after ACS. The analysis was performed on subgroups of main study participants. These patients had ACS of any type documented by coronary angiography with an ASP confirmed by ultrasound of the brachiocephalic arteries (BCA) during the index hospitalization. BCA ultrasound was performed to analyze the inter- and intra-study variability of BCA atherosclerotic load, the ASP total height (Hsum) and total area (ASPTA), in 20 and 24 patients of the main study, respectively. Results of the repeated ultrasound were evaluated in 30 patients of the main study after 6 months of follow-up.Results The inter-study variability of each index was significantly higher than the intra-study variability which was consistent with results of previous studies. The intra-study variability of Hsum was 0.10 (95 % confidence interval, CI - 0.23-0.44) mm and ASPTA, 1.05 (95 % CI, - 0.54-2.63) mm2. The variability values were considerably smaller than the changes for 6 months: Hsum, 0.92 (95 % CI, - 0.64-2.49) mm and ASPTA, 3.67 (95 % CI, 0.42-6.91) mm2, although the difference did not reach statistical significance. The above results were obtained at an early stage of the study during the adaptation of specialists to the protocol.Conclusion The study results suggest a possibility of a fairly reliable assessment of the dynamics of quantitative indexes of carotid ultrasound 6 months after ACS.
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Affiliation(s)
- L L Bershtein
- Mechnikov North-Western State Medical University, St-Petersburg
| | - S A Boldueva
- Mechnikov North-Western State Medical University, St-Petersburg
| | - I N Kochanov
- Mechnikov North-Western State Medical University, St-Petersburg
| | - M D Lunina
- Mechnikov North-Western State Medical University, St-Petersburg
| | - T V Naiden
- Mechnikov North-Western State Medical University, St-Petersburg
| | - D S Evdokimov
- Mechnikov North-Western State Medical University, St-Petersburg
| | - B M Tandelov
- Mechnikov North-Western State Medical University, St-Petersburg
| | - P S Podmetin
- Mechnikov North-Western State Medical University, St-Petersburg
| | | | - V E Gumerova
- Mechnikov North-Western State Medical University, St-Petersburg
| | | | | | - S A Sayganov
- Mechnikov North-Western State Medical University, St-Petersburg
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Chiarito M, Cao D, Sartori S, Zhang Z, Vogel B, Spirito A, Smith KF, Weintraub W, Strauss C, Toma C, DeFranco A, Effron MB, Stefanini G, Keller S, Kapadia S, Rao SV, Henry TD, Pocock S, Sharma S, Dangas G, Kini A, Baber U, Mehran R. Thrombotic risk in patients with acute coronary syndromes discharged on prasugrel or clopidogrel: results from the PROMETHEUS study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:594-603. [PMID: 37459570 DOI: 10.1093/ehjacc/zuad083] [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: 03/05/2023] [Revised: 05/21/2023] [Accepted: 06/02/2023] [Indexed: 09/27/2023]
Abstract
AIMS Based on recent clinical data, the 2020 ESC guidelines on non-ST-elevation acute coronary syndrome (NSTE-ACS) suggest to tailor antithrombotic strategy on individual thrombotic risk. Nonetheless, prevalence and prognostic impact of the high thrombotic risk (HTR) criteria proposed are yet to be described. In this analysis from the PROMETHEUS registry, we assessed prevalence and prognostic impact of HTR, defined according to the 2020 ESC NSTE-ACS guidelines, and if the benefits associated with prasugrel vs. clopidogrel vary with thrombotic risk. METHODS AND RESULTS PROMETHEUS was a multicentre prospective study comparing prasugrel vs. clopidogrel in ACS patients undergoing percutaneous coronary intervention (PCI). Patients were at HTR if presenting with one clinical plus one procedural risk feature. The primary endpoint was major adverse cardiac events (MACE), composite of death, myocardial infarction, stroke, or unplanned revascularization, at 1 year. Adjusted hazard ratio (adjHR) and 95% confidence intervals (CIs) were calculated with propensity score stratification and multivariable Cox regression. Among 16 065 patients, 4293 (26.7%) were at HTR and 11 772 (73.3%) at low-to-moderate thrombotic risk. The HTR conferred increased incidence of MACE (23.3 vs. 13.6%, HR 1.85, 95% CI 1.71-2.00, P < 0.001) and its single components. Prasugrel was prescribed in patients with less comorbidities and risk factors and was associated with reduced risk of MACE (HTR: adjHR 0.83, 95% CI 0.68-1.02; low-to-moderate risk: adjHR 0.75, 95% CI 0.64-0.88; pinteraction = 0.32). CONCLUSION High thrombotic risk, as defined by the 2020 ESC NSTE-ACS guidelines, is highly prevalent among ACS patients undergoing PCI. The HTR definition had a strong prognostic impact, as it successfully identified patients at increased 1 year risk of ischaemic events.
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Affiliation(s)
- Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
- Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, Milan, Italy
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Kenneth F Smith
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - William Weintraub
- Division of Cardiology, Christiana Care Health System, 313 W Main St, Newark, DE 19711, USA
| | - Craig Strauss
- Division of Cardiology, Minneapolis Heart Institute, 920 E 28th St #100, Minneapolis, MN 55407, USA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh Medical Center, 200 Meyran Ave # 318, Pittsburgh, PA 15213, USA
| | - Anthony DeFranco
- Division of Cardiology, Aurora Cardiovascular Services, 2801 W Kinnickinnic River Pkwy. Ste 777. Milwaukee, WI 53215, USA
| | - Mark B Effron
- Division of Cardiology, John Ochsner Heart and Vascular Institute, 1514 Jefferson Hwy, New Orleans, LA 70121, USA
| | - Giulio Stefanini
- Cardio Center, Humanitas Clinical and Research Hospital IRCCS, Via Alessandro Manzoni, 56, 20089 Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, Milan, Italy
| | - Stuart Keller
- Eli Lilly and Company, Sam Jones Expy, Indianapolis, IN 46241, USA
| | - Samir Kapadia
- Division of Cardiology, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Sunil V Rao
- Division of Cardiology, NYU Langone Health System, Skirball 9N, 530 1st Ave., New York, NY 10016, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, 2123 Auburn Ave # 424, Cincinnati, OH 45219, USA
- The Christ Hospital Heart and Vascular Institute, The Christ Hospital, 2139 Auburn Ave, Cincinnati, OH 45219, USA
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine,15-17 Tavistock Pl, London WC1H 9SH, UK
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
- Division of Cardiology, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave, Oklahoma City, OK 73104, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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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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Burgess SN, Shoaib A, Sharp ASP, Ludman P, Graham MM, Figtree GA, Kontopantelis E, Rashid M, Kinnaird T, Mamas MA. Sex-Specific Differences in Potent P2Y 12 Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI Patients. Circ Cardiovasc Interv 2023; 16:e012447. [PMID: 37725676 DOI: 10.1161/circinterventions.122.012447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Sex-based outcome differences for women with ST-segment-elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y12 inhibitors (P-P2Y12) is not well defined. This study explores the hypothesis that disparities in P-P2Y12 (prasugrel or ticagrelor) use may play a role in outcome disparities for women with STEMI. METHODS Data from British Cardiovascular Intervention Society national percutaneous coronary intervention database were analyzed, and 168 818 STEMI patients treated with primary percutaneous coronary intervention from 2010 to 2020 were included. RESULTS Among the included women (43 131; 25.54%) and men (125 687; 74.45%), P-P2Y12 inhibitors were prescribed less often to women (51.71%) than men (55.18%; P<0.001). Women were more likely to die in hospital than men (adjusted odds ratio, 1.213 [95% CI, 1.141-1.290]). Unadjusted mortality was higher among women treated with clopidogrel (7.57%), than P-P2Y12-treated women (5.39%), men treated with clopidogrel (4.60%), and P-P2Y12-treated men (3.61%; P<0.001). The strongest independent predictor of P-P2Y12 prescription was radial access (adjusted odds ratio, 2.368 [95% CI, 2.312-2.425]), used in 67.93% of women and 74.38% of men (P<0.001). Two risk adjustment models were used. Women were less likely to receive a P-P2Y12 (adjusted odds ratio, 0.957 [95% CI, 0.935-0.979]) with risk adjustment for baseline characteristics alone, when procedural factors including radial access were included in the model differences were not significant (adjusted odds ratio, 1.015 [95% CI, 0.991-1.039]). CONCLUSIONS Women were less likely to be prescribed prasugrel or ticagrelor, were less likely to have radial access, and had a higher mortality when being treated for STEMI. Improving rates of P-P2Y12 use and radial access may decrease outcome disparities for women with STEMI.
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Affiliation(s)
- Sonya N Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia (S.N.B.)
- University of Sydney, NSW, Australia (S.N.B.)
| | - Ahmad Shoaib
- Victoria Heart Institute Foundation (A.S.), Victoria, BC, Canada
- Royal Jubilee Hospital (A.S.), Victoria, BC, Canada
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
- Birmingham City Hospital, United Kingdom (A.S.)
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.L.)
| | - Michelle M Graham
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.)
| | - Gemma A Figtree
- Department of Cardiology, Kolling Institute, Royal North Shore Hospital and University of Sydney, Australia (G.A.F.)
| | | | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
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Agrawal RS, Yusuf J, Mahajan B, Mehta V, Mandal S, Mukhopadhyay S. Effect of prasugrel versus ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive strategy - acute and short-term results. Coron Artery Dis 2023; 34:381-388. [PMID: 37471285 DOI: 10.1097/mca.0000000000001265] [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] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Both ticagrelor and prasugrel are class I recommendations for treatment of ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) [ 1 ]. But clinical outcomes with the two drugs are conflicting which might be due to differential effects on coronary microcirculation. No study to date had compared the effects of prasugrel or ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive PCI (pPCI). AIM AND OBJECTIVE To compare the effects of prasugrel and ticagrelor on coronary microcirculation in STEMI patients undergoing pPCI as assessed by Myocardial Blush Grade (MBG). The secondary aim was to assess flow in the infarct-related artery by corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC) and whether a differential effect if detected on coronary microcirculation translated in improvement in left ventricular ejection fraction assessed at 6 months. MATERIAL AND METHODS A total of 240 patients with STEMI were evaluated in this open-label randomized control trial who initially underwent thrombolysis and later PCI (from 24 to 48 h) post-successful thrombolysis. The study subjects were randomized to receive either ticagrelor ( n = 120) or prasugrel ( n = 120) in 1 : 1 ratio 2 h prior to elective PCI. Patients underwent PCI according to standard protocol and post-procedure cTFC and MBG were compared. Patients were also followed up for 6 months to compare ejection fractions in both groups. We also assessed the effect of the two drugs on bleeding complications during hospitalization and over 6-month follow-up period. RESULTS There were no significant differences between the two groups with respect to baseline characteristics. Prasugrel administration resulted in higher MBG Grade 3 (50.86% vs 33.89%, P = 0.012) and lower cTFC (17.14 ± 4.08 vs 19.3 ± 4.06, P < 0.01). Improvement in ejection fraction was significantly higher with prasugrel compared to ticagrelor (10.29% ± 15.2 vs 4.66% ± 13.5, P = 0.003). Bleeding events at 6 months follow-up according to TIMI classification were similar in both the groups (11.86% vs 6.9%, P = 0.39). CONCLUSION Prasugrel produces greater improvement in coronary microcirculation than Ticagrelor resulting in improved myocardial salvage in patients of STEMI undergoing pPCI.
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Affiliation(s)
| | | | - Bhawna Mahajan
- Department of Biochemistry, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | | | - Sunil Mandal
- Department of Cardiology
- Department of Biochemistry, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Aijaz B, Glorioso TJ, Butala N, Waldo SW. Temporal trends and hospital variation in the use of P2Y12 inhibitors among patients undergoing percutaneous coronary intervention: Insights from the VA CART program. Catheter Cardiovasc Interv 2023; 102:503-504. [PMID: 37473421 DOI: 10.1002/ccd.30782] [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: 05/05/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Bilal Aijaz
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- Department of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Thomas J Glorioso
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
| | - Neel Butala
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- Department of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- Department of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia, USA
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Kuno T, Watanabe A, Shoji S, Fujisaki T, Ueyama H, Takagi H, Deharo P, Cuisset T, Bangalore S, Mehran R, Stone GW, Kohsaka S, Bhatt DL. Short-Term DAPT and DAPT De-Escalation Strategies for Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. Circ Cardiovasc Interv 2023; 16:e013242. [PMID: 37609850 DOI: 10.1161/circinterventions.123.013242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/13/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Short-term (≤6 months) dual antiplatelet therapy (DAPT) and DAPT de-escalation become attractive for patients with acute coronary syndrome. METHODS A systemic search identified randomized controlled trials that included patients with acute coronary syndrome treated using (1) standard DAPT (12 months) with clopidogrel, prasugrel (standard/low dose), or ticagrelor; (2) extended DAPT (≥18 months); (3) short-term DAPT (≤6 months) followed by P2Y12 inhibitor or aspirin; (4) 12-month DAPT with unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitor or clopidogrel at 1 month; and (5) guided selection DAPT with genotype or platelet function tests. The primary efficacy outcome (major adverse cardiovascular events) was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. RESULTS This meta-analysis included 32 randomized controlled trials with 103 497 patients. While there were no differences in efficacy between short, unguided de-escalation and guided selection strategies, unguided de-escalation was associated with reduced risk of major adverse cardiovascular events compared with standard DAPT with clopidogrel or ticagrelor (hazard ratio [95% CI], 0.67 [0.49-0.93] and 0.68 [0.50-0.93]). Both short DAPT followed by P2Y12 inhibitor and unguided de-escalation were associated with reduced risks in safety compared with other strategies, including guided selection (hazard ratio [95% CI], 0.66 [0.47-0.93] and 0.48 [0.33-0.71]). Short DAPT followed by a P2Y12 inhibitor was associated with reduced risk of major bleeding and all-cause death compared with standard, extended DAPT (eg, versus DAPT with clopidogrel; hazard ratio [95% CI], 0.64 [0.42-0.97] and 0.60 [0.44-0.82]). By rankogram, unguided de-escalation strategy was the safest and most effective strategy in reducing major adverse cardiovascular events and major or minor bleeding while short DAPT followed by P2Y12 inhibitor was ranked the best for major bleeding and all-cause death. CONCLUSIONS In patients with acute coronary syndrome, unguided de-escalation was associated with the lowest risk of major adverse cardiovascular events and major or minor bleeding outcomes, while short DAPT followed by P2Y12 inhibitor was associated with the lowest risk of major bleeding and all-cause death.
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Affiliation(s)
- Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center (T.K.), Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
- Division of Cardiology (T.K.), Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Atsuyuki Watanabe
- Department of Medicine, Mount Sinai Beth Israel (A.W.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
- Duke Clinical Research Institute, Durham, NC (S.S.)
| | - Tomohiro Fujisaki
- Department of Medicine, Mount Sinai Morningside and West (T.F.), Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan (T.F.)
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (T.F.)
| | - Hiroki Ueyama
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (H.U.)
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Japan (H.T.)
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.)
- INSERM, INRA, C2VN (P.D., T.C.), Aix-Marseille Université, France
- Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France (P.D., T.C.)
- INSERM, INRA, C2VN (P.D., T.C.), Aix-Marseille Université, France
- Faculté de Médecine (P.D., T.C.), Aix-Marseille Université, France
| | - Sripal Bangalore
- Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine (S.B.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute (R.M., G.W.S.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute (R.M., G.W.S.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.S., S.K.)
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY (D.L.B.)
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