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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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2
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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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Yu Y, Pan D, Bai R, Luo J, Tan Y, Duan W, Shi D. P2y 12 inhibitor monotherapy after 1-3 months dual antiplatelet therapy in patients with coronary artery disease and chronic kidney disease undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197161. [PMID: 37485257 PMCID: PMC10357506 DOI: 10.3389/fcvm.2023.1197161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction In patients with coronary artery disease (CAD) and chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), whether short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitors confers benefits compared with standard DAPT remains unclear. This study aimed to assess the efficacy and safety of 1-3 months of DAPT followed by P2Y12 monotherapy in patients with CAD and CKD undergoing PCI. Methods PubMed, Embase, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) comparing the P2Y12 inhibitor monotherapy after a 1-3 months DAPT vs. DAPT in patients with CAD and CKD after PCI. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, target-vessel revascularization, and stroke. The safety outcome was the major bleeding events, defined as a composite of TIMI major bleeding or Bleeding Academic Research and Consortium (BARC) type 2, 3, or 5 bleeding. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a fixed- or random-effects model depending on the heterogeneity among studies. Results Four RCTs including 20,468 patients (2,833 patients with CKD and 17,635 without CKD) comparing P2Y12 inhibitor monotherapy with DAPT were included in our meta-analysis. Patients with CAD and CKD had higher risk of ischemic and bleeding events. P2Y12 inhibitor monotherapy after 1-3 months of DAPT significantly reduced the risk of major bleeding compared to DAPT in CKD patients (RR: 0.69, 95% CI: 0.51-0.95, P = 0.02) and non-CKD patients (RR: 0.66, 95% CI: 0.49-0.89, P = 0.01). No significant difference regarding MACEs between P2Y12 inhibitor monotherapy and DAPT was found in CKD patients (RR: 0.88, 95% CI: 0.59-1.31, P = 0.53) and non-CKD (RR: 0.91, 95% CI: 0.79-1.04, P = 0.17). Conclusion P2Y12 inhibitor monotherapy after 1-3 months of DAPT was an effective strategy for lowering major bleeding complications without increasing the risk of cardiovascular events in patients with CAD and CKD undergoing PCI as compared with DAPT. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022355228.
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Affiliation(s)
- Yanqiao Yu
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruina Bai
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinwen Luo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Tan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenhui Duan
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Peng J. Klotho, a protective renal factor for platelet lifespan. J Thromb Haemost 2022; 20:2754-2755. [PMID: 36372445 DOI: 10.1111/jth.15886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/19/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Jun Peng
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong, China
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5
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Mourikis P, Zako S, Dannenberg L, M'Pembele R, Hohlfeld T, Zeus T, Kelm M, Veulemans V, Polzin A. Left ventricular-aortic angle is associated with platelet reactivity in patients with aortic stenosis. Blood Coagul Fibrinolysis 2022; 33:322-326. [PMID: 35867937 DOI: 10.1097/mbc.0000000000001147] [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: 11/26/2022]
Abstract
The impact of aortic stenosis on platelet reactivity is unclear. Previous studies reported contradicting results. The reason for this is unknown. It is known that flow alterations enhance platelet reactivity. A steep left ventricular-aortic angle (LV-AO-angle) is associated with turbulent flow in the aorta ascendens. Therefore, in this study, we hypothesized that LV-AO-angle is associated with platelet reactivity in patients with severe aortic stenosis. We included 289 patients with severe aortic stenosis and performed cardiac computertomography to assess the LV-AO-angle. Platelet function was evaluated by light transmission aggregometry. Platelet reactivity was higher in patients with a steep LV-AO-angle (ADP: <160°: 66.99% ± 20.72% vs. ≥160°: 60.66% ± 19.85%, P = 0.009; collagen: <160°: 78.67% ± 13.19% vs. ≥160°: 73.85% ± 14.44%, P = 0.003). Using Spearman correlation, ADP and collagen-induced aggregation was associated with LV-AO-angle (ADP: r = -0.19, P = 0.0009, R2 = 0.022; collagen: r = -0.21, P = 0.0004, R2 = 0.027). Apart from platelet reactivity, body weight, history of myocardial infarction and other factors were associated with steep LV-AO-angle. However, multivariate cox-regression (including body weight, comorbidities, history of MI and cardiac surgery, kidney function and laboratory parameters) revealed that LV-AO angle was a robust predictor of ADP and collagen-induced platelet aggregation. Steep LV-AO-angle is associated with enhanced platelet reactivity in patients with aortic stenosis. This could be the reason of contradicting results regarding platelet function in patients with aortic stenosis in previous studies. In addition, enhanced platelet reactivity in steep LV-AO-angle aortic stenosis patients might be a promising target in pathogenesis of aortic stenosis.
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Affiliation(s)
- Philipp Mourikis
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Saif Zako
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Rene M'Pembele
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Thomas Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Dusseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Verena Veulemans
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf
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Berger M, Baaten CCFMJ, Noels H, Marx N, Schütt K. [Heart and diabetes : Platelet function and antiplatelet therapy in chronic kidney disease]. Herz 2022; 47:426-433. [PMID: 35861809 DOI: 10.1007/s00059-022-05129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/04/2022]
Abstract
Patients with chronic kidney disease (CKD) have an increased risk of thrombosis and approximately 50% of patients with advanced CKD die because of a cardiovascular disease. In addition to an increased risk of thrombosis, patients with CKD and particularly with advanced CKD, have an increased risk of hemorrhage, which increases parallel to the decline of kidney function. Due to this parallel existence of the prohemorrhagic and prothrombotic phenotype, antiplatelet treatment is difficult in the daily routine and data show that CKD patients with acute coronary syndrome (ACS) are less likely to receive guideline-conform treatment. The underlying mechanisms are currently insufficiently understood and both platelet-dependent mechanisms and also platelet-independent mechanisms are under discussion. Accordingly, there is currently no specific treatment or treatment strategy for patients with CKD. In addition, CKD patients are underrepresented in registration studies on antiplatelet treatment and there are no data from randomized trials for patients with advanced CKD (CKD ≥ 4). Current guideline recommendations are therefore based on subgroup analyses and observational studies. In addition, questions on the duration of treatment, on risk scores for estimation of the risk of hemorrhage and on potential benefits of escalation and de-escalation strategies remain largely unanswered and should therefore be the focus of future studies.
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Affiliation(s)
- Martin Berger
- Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Deutschland.
| | - Constance C F M J Baaten
- Institut für Molekulare Herz-Kreislauf-Forschung (IMCAR), RWTH Aachen University, Aachen, Deutschland.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Niederlande
| | - Heidi Noels
- Institut für Molekulare Herz-Kreislauf-Forschung (IMCAR), RWTH Aachen University, Aachen, Deutschland.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Niederlande
| | - Nikolaus Marx
- Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Deutschland
| | - Katharina Schütt
- Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Deutschland
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7
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Gong W, Zhang X, Meng Z, Liu F, Li G, Xiao J, Liu P, Sun Y, Liu T, Wang H, Zhang Y, Wang N. Factors Influencing the Outcome of Symptomatic Intracranial Artery Stenosis With Hemodynamic Impairment After Short and Long-Term Stent Placement. Front Neurol 2022; 13:682694. [PMID: 35655616 PMCID: PMC9152452 DOI: 10.3389/fneur.2022.682694] [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: 03/19/2021] [Accepted: 04/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Stent placement is a feasible approach worldwidely for patients with symptomatic intracranial artery stenosis (sICAS) and hemodynamic impairment (HI) who are at high risk of recurrent stroke after medical treatment. Exploration of factors associated with poor outcomes after stent placement could help develop better individualized therapeutic strategies. Methods This study conducted a post-hoc analysis of a prospective, multicenter registry study of stent use for sICAS with HI in China. Patient and clinical demographics, and stenotic lesion images were analyzed using univariate and multivariate Cox regression to the time until any endpoints or the end of the follow-up period. The short-term endpoint included any transient ischemic attack (TIA), stroke, or death within 1 month after stent placement. The long-term endpoints included the short-term endpoints and any TIA or stroke in the region of the affected artery that occurred more than 1 month after stent placement. Results Two hundred and ninety two patients were included, with 13 short-term and 39 long-term endpoints. Multivariate Cox regression analysis revealed that lesions at the arterial origin or bifurcation (Hazard Ratio (HR) = 7.52; 95% CI, 1.89-29.82; p = 0.004) were significantly associated with higher short-term risk. Baseline renal insufficiency reduced the risk (HR = 0.08; 95% CI: 0.01-0.68; p = 0.021). Factors significantly associated with higher long-term risk included irregular or ulcerated plaques at the lesion (HR = 2.15; 95% CI: 1.07-4.33; p = 0.031). Subgroup analyses indicated that higher risk occurred in the older age group (age>59 years, HR = 3.73, 95% CI: 1.27-10.97, p = 0.017), and not in the younger group (age≤59 years, HR = 1.12, 95% CI: 0.42-3.03, p = 0.822). Conclusion Irregular or ulcerated plaques in older patients and lesions at the arterial opening or bifurcation were more likely to result in adverse endpoints for stent placement during long or short -term follow-up. Investigation of these factors might facilitate the development of individualized therapeutic strategies for this population. Clinical Trial Registration http://www.clinicaltrials.gov, identifier: NCT01968122.
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Affiliation(s)
- Wentao Gong
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xianjun Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhen Meng
- Department of Interventional Operating Room, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Feifei Liu
- Department of General Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guangwen Li
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Juan Xiao
- Department of Evidence-Based Medicine, The Second Hospital of Shandong University, Jinan, China
| | - Peng Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yujie Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tonghui Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hongxia Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Naidong Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
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8
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Oh H, Park HE, Song MS, Kim H, Baek JH. The Therapeutic Potential of Anticoagulation in Organ Fibrosis. Front Med (Lausanne) 2022; 9:866746. [PMID: 35652066 PMCID: PMC9148959 DOI: 10.3389/fmed.2022.866746] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
Fibrosis, also known as organ scarring, describes a pathological stiffening of organs or tissues caused by increased synthesis of extracellular matrix (ECM) components. In the past decades, mounting evidence has accumulated showing that the coagulation cascade is directly associated with fibrotic development. Recent findings suggest that, under inflammatory conditions, various cell types (e.g., immune cells) participate in the coagulation process causing pathological outcomes, including fibrosis. These findings highlighted the potential of anticoagulation therapy as a strategy in organ fibrosis. Indeed, preclinical and clinical studies demonstrated that the inhibition of blood coagulation is a potential intervention for the treatment of fibrosis across all major organs (e.g., lung, liver, heart, and kidney). In this review, we aim to summarize our current knowledge on the impact of components of coagulation cascade on fibrosis of various organs and provide an update on the current development of anticoagulation therapy for fibrosis.
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Hariharan NN, Patel K, Sikder O, Perera KS, Diener HC, Hart RG, Eikelboom JW. Oral anticoagulation versus antiplatelet therapy for secondary stroke prevention in patients with embolic stroke of undetermined source: A systematic review and meta-analysis. Eur Stroke J 2022; 7:92-98. [PMID: 35647310 PMCID: PMC9134773 DOI: 10.1177/23969873221076971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/12/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose We performed a systematic review and meta-analysis of randomized
controlled trials (RCTs) to evaluate the efficacy and safety of
direct oral anticoagulation (DOAC) compared with antiplatelet
therapy for secondary stroke prevention in adult patients with
embolic stroke of undetermined source (ESUS). Method We searched major databases (Embase, MEDLINE, CINAHL, CENTRAL, and
Web of Science) for RCTs published until March 2021. The primary
outcome was recurrent stroke, and the main safety outcomes were
major bleeding and clinically relevant non-major bleeding
(CRNB). We assessed risk of bias using the Cochrane Risk of Bias
tool. We used a random-effects model to determine pooled risk
ratios and 95% confidence intervals in the datasets and key
subgroups. Findings Our search identified two RCTs, involving a total of 12,603
patients with ESUS. Anticoagulation with dabigatran or
rivaroxaban compared with aspirin did not reduce the risk of
recurrent stroke (RR, 0.96 [0.76–1.20]) or increase major
bleeding (RR, 1.77 [0.80–3.89]) but significantly increased the
composite of major or clinically relevant non-major bleeding
(RR, 1.57 [1.26–1.97]). Prespecified subgroup analysis
demonstrated consistent results according to age and sex.
Additional post-hoc subgroup analyses demonstrated consistent
results according to prior stroke and presence of a patent
foramen ovale but suggested that DOACs reduced recurrent stroke
in patients with an estimated glomerular filtration rate (eGFR)
<50 and 50-80 ml/min but not in those with eGFR >80 ml/min
(interaction P = 0.0234). Discussion/conclusion Direct oral anticoagulations are not more effective than aspirin in
preventing stroke recurrence in patients with ESUS and increase
bleeding. Registration PROSPERO ID: CRD42019138593
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Affiliation(s)
| | - Kashyap Patel
- School of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Kanjana S Perera
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Robert G Hart
- McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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10
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Wang Y, Gao L. Inflammation and Cardiovascular Disease Associated With Hemodialysis for End-Stage Renal Disease. Front Pharmacol 2022; 13:800950. [PMID: 35222026 PMCID: PMC8867697 DOI: 10.3389/fphar.2022.800950] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/10/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) and cardiac insufficiency often co-exist, particularly in uremic patients on hemodialysis (HD). The occurrence of abnormal renal function in patients with cardiac insufficiency is often indicative of a poor prognosis. It has long been established that in patients with cardiac insufficiency, poorer renal function tends to indicate poorer cardiac mechanics, including left atrial reserve strain, left ventricular longitudinal strain, and right ventricular free wall strain (Unger et al., Eur J Heart Fail, 2016, 18(1), 103–12). Similarly, patients with chronic kidney disease, particularly uremic patients on HD, often have cardiovascular complications in addition to abnormal endothelial function with volume overload, persistent inflammatory states, calcium overload, and imbalances in redox responses. Cardiac insufficiency due to uremia is therefore mainly due to multifaceted non-specific pathological changes rather than pure renal insufficiency. Several studies have shown that the risk of adverse cardiovascular events is greatly increased and persistent in all patients treated with HD, especially in those who have just started HD treatment. Inflammation, as an important intersection between CKD and cardiovascular disease, is involved in the development of cardiovascular complications in patients with CKD and is indicative of prognosis (Chan et al., Eur Heart J, 2021, 42(13), 1244–1253). Therefore, only by understanding the mechanisms underlying the sequential development of inflammation in CKD patients and breaking the vicious circle between inflammation-mediated renal and cardiac insufficiency is it possible to improve the prognosis of patients with end-stage renal disease (ESRD). This review highlights the mechanisms of inflammation and the oxidative stress that co-exists with inflammation in uremic patients on dialysis, as well as the mechanisms of cardiovascular complications in the inflammatory state, and provides clinical recommendations for the anti-inflammatory treatment of cardiovascular complications in such patients.
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11
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Baaten CC, Schröer JR, Floege J, Marx N, Jankowski J, Berger M, Noels H. Platelet Abnormalities in CKD and Their Implications for Antiplatelet Therapy. Clin J Am Soc Nephrol 2022; 17:155-170. [PMID: 34750169 PMCID: PMC8763166 DOI: 10.2215/cjn.04100321] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with CKD display a significantly higher risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hyporeactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. In this study, we summarize the knowledge on CKD-induced aberrations in hemostasis, with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation, and red blood cell count in CKD may contribute to altered hemostasis in these patients who are high risk. Furthermore, with patients with CKD commonly receiving antiplatelet therapy to prevent secondary atherothrombotic complications, we discuss antiplatelet treatment strategies and their risk versus benefit in terms of thrombosis prevention, bleeding, and clinical outcome depending on CKD stage. This reveals a careful consideration of benefits versus risks of antiplatelet therapy in patients with CKD, balancing thrombotic versus bleeding risk. Nonetheless, despite antiplatelet therapy, patients with CKD remain at high cardiovascular risk. Thus, deep insights into altered platelet activity in CKD and underlying mechanisms are important for the optimization and development of current and novel antiplatelet treatment strategies, specifically tailored to these patients who are high risk. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and antiplatelet therapy in patients with CKD.
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Affiliation(s)
- Constance C.F.M.J. Baaten
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jonas R. Schröer
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Joachim Jankowski
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Martin Berger
- Department of Internal Medicine I, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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12
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Polzin A, Dannenberg L, Helten C, Pöhl M, Metzen D, Mourikis P, Dücker C, Marschall U, L'Hoest H, Hennig B, Zako S, Trojovsky K, Petzold T, Jung C, Levkau B, Zeus T, Schrör K, Hohlfeld T, Kelm M. Excess Mortality in Aspirin and Dipyrone (Metamizole) Co-Medicated in Patients With Cardiovascular Disease: A Nationwide Study. J Am Heart Assoc 2021; 10:e022299. [PMID: 34726072 PMCID: PMC8751960 DOI: 10.1161/jaha.121.022299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Pain is a major issue in our aging society. Dipyrone (metamizole) is one of the most frequently used analgesics. Additionally, it has been shown to impair pharmacodynamic response to aspirin as measured by platelet function tests. However, it is not known how this laboratory effect translates to clinical outcome. Methods and Results We conducted a nationwide analysis of a health insurance database in Germany comprising 9.2 million patients. All patients with a cardiovascular event in 2014 and subsequent secondary prevention with aspirin were followed up for 36 months. Inverse probability of treatment weighting analysis was conducted to investigate the rate of mortality, myocardial infarction, and stroke/transient ischemic attack between patients on aspirin‐dipyrone co‐medication compared with aspirin‐alone medication. Permanent aspirin‐alone medication was given to 26,200 patients, and 5946 patients received aspirin–dipyrone co‐medication. In the inverse probability of treatment weighted sample, excess mortality in aspirin–dipyrone co‐medicated patients was observed (15.6% in aspirin‐only group versus 24.4% in the co‐medicated group, hazard ratio [HR], 1.66 [95% CI, 1.56–1.76], P<0.0001). Myocardial infarction and stroke/transient ischemic attack were increased as well (myocardial infarction: 1370 [5.2%] versus 355 [5.9%] in aspirin‐only and co‐medicated groups, respectively; HR, 1.18 [95% CI, 1.05–1.32]; P=0.0066, relative risk [RR], 1.14; number needed to harm, 140. Stroke/transient ischemic attack, 1901 [7.3%] versus 506 [8.5%] in aspirin‐only and co‐medicated groups, respectively; HR, 1.22 [95% CI, 1.11–1.35]; P<0.0001, RR, 1.17, number needed to harm, 82). Conclusions In this observational, nationwide analysis, aspirin and dipyrone co‐medication was associated with excess mortality. This was in part driven by ischemic events (myocardial infarction and stroke), which occurred more frequently in co‐medicated patients as well. Hence, dipyrone should be used with caution in aspirin‐treated patients for secondary prevention.
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Affiliation(s)
- Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Carolin Helten
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Martin Pöhl
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Daniel Metzen
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Philipp Mourikis
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Christof Dücker
- Institute for Clinical Pharmacology University Medical Center GöttingenGeorg-August University Göttingen Germany
| | - Ursula Marschall
- Department of Medicine and Health Services Research BARMER Statutory Health Insurance Fund Wuppertal Germany
| | - Helmut L'Hoest
- Department of Medicine and Health Services Research BARMER Statutory Health Insurance Fund Wuppertal Germany
| | - Beata Hennig
- Department of Medicine and Health Services Research BARMER Statutory Health Insurance Fund Wuppertal Germany
| | - Saif Zako
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Kajetan Trojovsky
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Tobias Petzold
- Medizinische Klinik und Poliklinik I Klinikum der Universität MünchenLudwig-Maximilians- University Munich Munich Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Bodo Levkau
- Institute of Molecular Medicine III University Hospital DüsseldorfHeinrich Heine University Düsseldorf Dusseldorf Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
| | - Karsten Schrör
- Institute for Pharmacology and Clinical Pharmacology Heinrich Heine University Dusseldorf Germany
| | - Thomas Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology Heinrich Heine University Dusseldorf Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID) Heinrich Heine University Medical Center Düsseldorf Düsseldorf Germany
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Hazardous Effect of Low-Dose Aspirin in Patients with Predialysis Advanced Chronic Kidney Disease Assessed by Machine Learning Method Feature Selection. Healthcare (Basel) 2021; 9:healthcare9111484. [PMID: 34828530 PMCID: PMC8625790 DOI: 10.3390/healthcare9111484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/18/2021] [Accepted: 10/28/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Low-dose aspirin (100 mg) is widely used in preventing cardiovascular disease in chronic kidney disease (CKD) because its benefits outweighs the harm, however, its effect on clinical outcomes in patients with predialysis advanced CKD is still unclear. This study aimed to assess the effect of aspirin use on clinical outcomes in such group. Methods: Patients were selected from a nationwide diabetes database from January 2009 to June 2017, and divided into two groups, a case group with aspirin use (n = 3021) and a control group without aspirin use (n = 9063), by propensity score matching with a 1:3 ratio. The Cox regression model was used to estimate the hazard ratio (HR). Moreover, machine learning method feature selection was used to assess the importance of parameters in the clinical outcomes. Results: In a mean follow-up of 1.54 years, aspirin use was associated with higher risk for entering dialysis (HR, 1.15 [95%CI, 1.10-1.21]) and death before entering dialysis (1.46 [1.25-1.71]), which were also supported by feature selection. The renal effect of aspirin use was consistent across patient subgroups. Nonusers and aspirin users did not show a significant difference, except for gastrointestinal bleeding (1.05 [0.96-1.15]), intracranial hemorrhage events (1.23 [0.98-1.55]), or ischemic stroke (1.15 [0.98-1.55]). Conclusions: Patients with predialysis advanced CKD and anemia who received aspirin exhibited higher risk of entering dialysis and death before entering dialysis by 15% and 46%, respectively.
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14
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Lee KH, Ou SM, Chu YC, Lin YP, Tsai MT, Tarng DC. Antithrombotic Therapy for Chronic Kidney Disease Patients With Concomitant Atrial Fibrillation and Coronary Artery Disease. Front Cardiovasc Med 2021; 8:751359. [PMID: 34692798 PMCID: PMC8531471 DOI: 10.3389/fcvm.2021.751359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/15/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Oral anticoagulants (OAC) plus antiplatelets is recommended for patients with atrial fibrillation (AF) and coronary artery disease (CAD) to reduce thromboembolism. However, there is limited evidence regarding antithrombotic therapy for patients with concomitant chronic kidney disease (CKD), AF, and CAD, especially those not undergoing percutaneous coronary intervention. We aimed to use real-world data assessing the efficacy and safety of antithrombotic regimens in this population. Methods: We used a single-center database of 142,624 CKD patients to identify those receiving antithrombotic therapy for AF and CAD between 2010 and 2018. Patients taking warfarin or direct OAC (DOAC) alone were grouped in the OAC monotherapy (n = 537), whereas those taking OAC plus antiplatelets were grouped in the combination therapy (n = 2,391). We conducted propensity score matching to balance baseline covariates. The endpoints were all-cause mortality, major adverse cardiovascular events, and major bleedings. Results: After 1:4 matching, the number of patients in OAC monotherapy and combination therapy were 413 and 1,652, respectively. Between the two groups, combination therapy was associated with higher risks for ischemic stroke (HR 2.37, CI 1.72–3.27), acute myocardial infarction (HR 6.14, CI 2.51–15.0), and hemorrhagic stroke (HR 3.57, CI 1.35–9.81). The results were consistent across CKD stages. In monotherapy, DOAC users were associated with lower risks for all-cause mortality, AMI, and gastrointestinal bleeding than warfarin, but the stroke risk was similar between the two subgroups. Conclusions: For patients with concomitant CKD, AF and CAD not undergoing PCI, OAC monotherapy may reduce stroke and AMI risks. DOAC showed more favorable outcomes than warfarin.
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Affiliation(s)
- Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan
| | - Shuo-Ming Ou
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan
| | - Yuan-Chia Chu
- Information Management Office, Taipei Veterans General Hospital, Taipei City, Taiwan.,Big Data Center, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Yao-Ping Lin
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan
| | - Ming-Tsun Tsai
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei City, Taiwan.,Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan.,Department and Institute of Physiology, National Yang-Ming University, Taipei City, Taiwan
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15
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Thromboxane A 2 is involved in the development of hypertension in chronic kidney disease rats. Eur J Pharmacol 2021; 909:174435. [PMID: 34416239 DOI: 10.1016/j.ejphar.2021.174435] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/21/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022]
Abstract
Hypertension is one of the most common complications of chronic kidney disease (CKD). Some research has indicated that changes in large artery function especially caused by thromboxane A2 (TXA2) may be a novel factor acting to induce hypertension in CKD. We studied the 5/6 nephrectomy rat model and measured serum levels of creatinine (Cr), calcium (Ca), phosphorus (P), TXA2-stable metabolites (thromboxane B2, TXB2), and caudal artery pressure after nephrectomy. The tension variations in thoracic aortas were measured after stimulating by vasoconstrictor/vasodilator using the cumulative concentration administration method and then tested the expression of TXA2 receptors in the thoracic aortas through western blots. The CKD rats developed uremia, electrolyte imbalances,and hypertension. They also exhibited a significant increase in TXB2 concentration. The aortic rings of CKD rats showed an increased contraction response to U46619 (a TXA2 analogue) and the expression of TXA2 receptors also enhanced. In the meanwhile, the diastolic function decreased in the CKD group. Our results demonstrate that the impairment of artery contractile function caused by the increase of TXA2 receptors on the wall of aortic rings may be involved in hypertension in CKD rats.
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16
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Busch L, Stern M, M'Pembele R, Dannenberg L, Mourikis P, Gröne M, Özaslan G, Heinen Y, Heiss C, Sansone R, Huhn R, Kelm M, Polzin A. Impact of high on-treatment platelet reactivity after angioplasty in patients with critical limb ischemia. Vascul Pharmacol 2021; 141:106925. [PMID: 34619361 DOI: 10.1016/j.vph.2021.106925] [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: 06/20/2021] [Revised: 07/31/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is standard of care in patients with peripheral artery disease (PAD) after percutaneous transluminal angioplasty (PTA). However, high on treatment platelet reactivity (HTPR) to DAPT is frequent and associated with major adverse limb events (MALE) in PAD patients. Nevertheless, association of MALE and HTPR in patients with critical limb ischemia (CLI) is not known. Moreover, comorbidities might confound response to antiplatelet medication further. Hence, in this trial we analyzed pharmacodynamic responses to DAPT and clinical events in CLI patients post PTA. METHODS In this prospective single center pilot analysis, we included 71 CLI patients. Patients received DAPT after PTA. Antiplatelet effect were measured by light transmission aggregometry (LTA) and vasodilator-stimulated protein phosphorylation assay (VASP). MALE, major adverse cardiac and cerebrovascular events (MACCE) and BARC bleeding within 12 months follow-up were assessed. RESULTS Mean age of patients was 73.37 ± 7.36 years and 47 (66.2%) were male. Overall HTPR appeared in 46 patients (64.8%). MALE and MACCE showed no differences between patients with and patients without HTPR. However, bleeding was higher in patients with sufficient pharmacodynamic response to DAPT (Bleeding - HTPR: 13.4% vs. no HTPR: 36.0%; log-rank HR: 0.32; 95% CI 0.1079 to 0.9396 p = 0.0217). This finding remained robust in multivariate analysis. CONCLUSION HTPR to DAPT is frequent in CLI patients. However, bleeding was higher in patients with sufficient response to DAPT. Ischemic events did not differ. Hence, CLI patients might benefit from an alternative antithrombotic approach.
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Affiliation(s)
- Lucas Busch
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Manuel Stern
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - René M'Pembele
- Departement of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Lisa Dannenberg
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Philipp Mourikis
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Michael Gröne
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Göksen Özaslan
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Yvonne Heinen
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Christian Heiss
- University of Surrey, Faculty of Health and Medical Sciences, Guildford, United Kingdom
| | - Roberto Sansone
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Ragnar Huhn
- Departement of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Malte Kelm
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Amin Polzin
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
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17
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Jain N, Corken AL, Kumar A, Davis CL, Ware J, Arthur JM. Role of Platelets in Chronic Kidney Disease. J Am Soc Nephrol 2021; 32:1551-1558. [PMID: 34140394 PMCID: PMC8425650 DOI: 10.1681/asn.2020121806] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 02/04/2023] Open
Abstract
Platelet-dependent mechanisms for excessive clotting and bleeding in CKD remain undefined. Moreover, platelets' contribution to inflammation, and specifically to CKD, are equally elusive. To date, descriptions of changes in the functional properties of circulating platelets during CKD have provided confusing interpretations. Experimental approaches that can advance our understanding of platelet dysfunction in CKD are needed, and studies that provide mechanistic insights into the dynamic relationships between thrombosis, bleeding, and inflammation associated with CKD will be essential to improve clinical management and outcomes for this vulnerable population. This article summarizes existing literature characterizing platelets in CKD and identifies areas that need further investigation.
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Affiliation(s)
- Nishank Jain
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
| | - Adam L. Corken
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Amudha Kumar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Clayton L. Davis
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jerry Ware
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - John M. Arthur
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Medicine Service, Central Arkansas Veterans Affairs Medical Center, Little Rock, Arkansas
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18
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The risk of major bleeding event in patients with chronic kidney disease on pentoxifylline treatment. Sci Rep 2021; 11:13521. [PMID: 34188087 PMCID: PMC8241975 DOI: 10.1038/s41598-021-92753-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/07/2021] [Indexed: 12/17/2022] Open
Abstract
Patients with chronic kidney diseases (CKD) are often treated with antiplatelets due to aberrant haemostasis. This study aimed to evaluate the bleeding risk with CKD patients undergoing pentoxifylline (PTX) treatment with/without aspirin. In this retrospective study, we used Taiwan’s National Health Insurance Research Database to identify PTX treated CKD patients. Patients undergoing PTX treatment after CKD diagnosis were PTX group. A 1:4 age, sex and aspirin used condition matched CKD patients non-using PTX were identified as controls. The outcome was major bleeding event (MBE: intracranial haemorrhage (ICH) and gastrointestinal tract bleeding) during 2-year follow-up period. Risk factors were estimated using Cox regression for overall and stratified analysis. The PTX group had higher MBE risk than controls (hazard ratio (HR) 1.19; 95% confidence interval (CI) 0.94–1.50). In stratified analysis, hyperlipidaemia was a significant risk factor (HR: 1.42; 95% CI 1.01–2.01) of MBE. A daily PTX dose larger than 800 mg, females, non-regular aspirin usage, and ischaemic stroke were risk factors for MBE in PTX group. When prescribing PTX in CKD patients, bleeding should be closely monitored, especially in those with daily dose more than 800 mg, aspirin users, and with a history of ischaemic stroke.
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19
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Liang W, Zhang P, Liu M. Association between renal function and platelet reactivity during aspirin therapy in elderly patients with atherosclerotic cardiovascular disease. BMC Geriatr 2021; 21:75. [PMID: 33482738 PMCID: PMC7821654 DOI: 10.1186/s12877-021-02018-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/11/2021] [Indexed: 11/12/2022] Open
Abstract
Background Aspirin is the key treatment in the secondary prevention of atherosclerotic cardiovascular disease. High on-treatment platelet reactivity (HTPR) to aspirin has been reported to partially account for the enhanced risk of thrombotic events. In particular, HTPR has been described more frequently among elderly patients. The aim of this study was to identify the clinical and biological factors associated with HTPR in a real-life elderly population. Methods In this retrospective study, elderly patients with atherosclerotic cardiovascular disease on regular aspirin treatment were enrolled. Cardiovascular risk factors, routine biological parameters, comorbidities, and concomitant medications were recorded. The upper quartile of the platelet aggregation rate, determined by light transmission aggregometry with arachidonic acid, was defined as the HTPR group. Results A total of 304 patients were included (mean age 77 ± 8 years, 76% men). Patients in the HTPR group were older than the patients in the non-HTPR group (mean age: 79 ± 7 vs. 76 ± 8 years, p = 0.008). Patients with moderately decreased estimated glomerular filtration rate (eGFR) had a higher frequency of HTPR than patients with slightly decreased eGFR or normal eGFR (35.8, 22.5, 12.2%, respectively, p < 0.05). In multivariate analysis, an independent risk factor for HTPR was the eGFR (OR: 0.984, 95% CI: 0.980–0.988, p < 0.001). Conclusions Advanced age and decreased eGFR are correlated with poor pharmacodynamic response to aspirin.
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Affiliation(s)
- Wenyi Liang
- Department of Geriatrics, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Peng Zhang
- Department of Geriatrics, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Meilin Liu
- Department of Geriatrics, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China.
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20
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Wiśniewski A. Multifactorial Background for a Low Biological Response to Antiplatelet Agents Used in Stroke Prevention. ACTA ACUST UNITED AC 2021; 57:medicina57010059. [PMID: 33435185 PMCID: PMC7827369 DOI: 10.3390/medicina57010059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/27/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
Effective platelet inhibition is the main goal of the antiplatelet therapy recommended as a standard treatment in the secondary prevention of non-embolic ischemic stroke. Acetylsalicylic acid (aspirin) and clopidogrel are commonly used for this purpose worldwide. A low biological response to antiplatelet agents is a phenomenon that significantly reduces the therapeutic and protective properties of the therapy. The mechanisms leading to high on-treatment platelet reactivity are still unclear and remain multifactorial. The aim of the current review is to establish the background of resistance to antiplatelet agents commonly used in the secondary prevention of ischemic stroke and to explain the possible mechanisms. The most important factors influencing the incidence of a low biological response were demonstrated. The similarities and the differences in resistance to both drugs are emphasized, which may facilitate the selection of the appropriate antiplatelet agent in relation to specific clinical conditions and comorbidities. Despite the lack of indications for the routine assessment of platelet reactivity in stroke subjects, this should be performed in selected patients from the high-risk group. Increasing the detectability of low antiaggregant responders, in light of its negative impact on the prognosis and clinical outcomes, can contribute to a more individualized approach and modification of the antiplatelet therapy to maximize the therapeutic effect in the secondary prevention of stroke.
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Affiliation(s)
- Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Skłodowskiej 9 Street, 85-094 Bydgoszcz, Poland
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21
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Kim JT, Kim BJ, Park JM, Lee SJ, Cha JK, Park TH, Lee KB, Lee J, Hong KS, Lee BC, Kim DE, Choi JC, Kwon JH, Shin DI, Sohn SI, Lee JS, Lee J, Bae HJ. Risk of recurrent stroke and antiplatelet choice in breakthrough stroke while on aspirin. Sci Rep 2020; 10:16723. [PMID: 33028887 PMCID: PMC7541489 DOI: 10.1038/s41598-020-73836-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 09/15/2020] [Indexed: 11/09/2022] Open
Abstract
Uncertainty regarding an optimal antiplatelet regimen still exists in patients with breakthrough acute ischemic stroke (AIS) while on aspirin. This study provides an analysis of a prospective multicenter registry between April 2008 and April 2014. Eligible patients were on aspirin at the time of AIS and treated with antiplatelet regimens (aspirin, clopidogrel, or clopidogrel-aspirin). Potential factors associated with the choice of each antiplatelet regimen were explored and included a predictive risk score for future vascular events, the Essen Stroke Risk Score (ESRS). A total of 2348 patients (age, 69 ± 11 years; male, 57.7%) were analyzed, and 55.3%, 25.3% and 19.4% were treated with clopidogrel-aspirin, aspirin and clopidogrel, respectively. While the likelihood of choosing clopidogrel-aspirin increased as the ESRS increased, the likelihood of choosing aspirin decreased as the ESRS increased (Ptrend < 0.001). The ESRS category (0-1/2-3/ ≥ 4) modified the effect of antiplatelet regimens for 1-year vascular events (Pinteraction < 0.01). Among patients with ESRS ≥ 4, clopidogrel-aspirin (HR 0.47 [0.30-0.74]) and clopidogrel (HR 0.30 [0.15-0.60]) significantly reduced the risk of outcome events. Our study showed that more than half of the patients with aspirin failure were treated with clopidogrel-aspirin. In particular, a higher ESRS, which indicates an increased risk of recurrent stroke, was associated with the choice of clopidogrel-aspirin rather than aspirin.
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Affiliation(s)
- Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Republic of Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Republic of Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Republic of Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Republic of Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Ulsan, Republic of Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
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22
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Polzin A, Dannenberg L, Thienel M, Orban M, Wolff G, Hohlfeld T, Zeus T, Kelm M, Petzold T. Noncanonical Effects of Oral Thrombin and Factor Xa Inhibitors in Platelet Activation and Arterial Thrombosis. Thromb Haemost 2020; 121:122-130. [PMID: 32942315 DOI: 10.1055/s-0040-1716750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nonvitamin K oral anticoagulants (NOACs) or direct oral anticoagulants comprise inhibitors of factor Xa (rivaroxaban, apixaban, edoxaban) or factor IIa (dabigatran). Both classes efficiently interfere with the final or penultimate step of the coagulation cascade and showed superior net clinical benefit compared with vitamin K antagonists for prevention of thromboembolic events in patients with AF and for prevention and therapy of deep vein thrombosis and pulmonary embolism. None the less, accumulating data suggested, that there may be differences regarding the frequency of atherothrombotic cardiovascular events between NOACs. Thus, the optimal individualized NOAC for each patient remains a matter of debate. Against this background, some basic and translational analyses emphasized NOAC effects that impact on platelet activity and arterial thrombus formation beyond inhibition of plasmatic coagulation. In this review, we will provide an overview of the available clinical and translational evidence for so-called noncanonical NOAC effects on platelet activation and arterial thrombosis.
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Affiliation(s)
- Amin Polzin
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Lisa Dannenberg
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Manuela Thienel
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
| | - Martin Orban
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Thomas Hohlfeld
- Instituton of Pharmacology and Clinical Pharmacology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Petzold
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
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23
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Miglinas M, Cesniene U, Janusaite MM, Vinikovas A. Cerebrovascular Disease and Cognition in Chronic Kidney Disease Patients. Front Cardiovasc Med 2020; 7:96. [PMID: 32582768 PMCID: PMC7283453 DOI: 10.3389/fcvm.2020.00096] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 05/06/2020] [Indexed: 12/16/2022] Open
Abstract
Chronic kidney disease (CKD) affects both brain structure and function. Patients with CKD have a higher risk of both ischemic and hemorrhagic strokes. Age, prior disease history, hypertension, diabetes, atrial fibrillation, smoking, diet, obesity, and sedimentary lifestyle are most common risk factors. Renal-specific pathophysiologic derangements, such as oxidative stress, chronic inflammation, endothelial dysfunction, vascular calcification, anemia, gut dysbiosis, and uremic toxins are important mediators. Dialysis initiation constitutes the highest stroke risk period. CKD significantly worsens stroke outcomes. It is essential to understand the risks and benefits of established stroke therapeutics in patients with CKD, especially in those on dialysis. Subclinical cerebrovascular disease, such as of silent brain infarction, white matter lesions, cerebral microbleeds, and cerebral atrophy are more prevalent with declining renal function. This may lead to functional brain damage manifesting as cognitive impairment. Cognitive dysfunction has been linked to poor compliance with medications, and is associated with greater morbidity and mortality. Thus, understanding the interaction between renal impairment and brain is important in to minimize the risk of neurologic injury in patients with CKD. This article reviews the link between chronic kidney disease and brain abnormalities associated with CKD in detail.
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Affiliation(s)
- Marius Miglinas
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ugne Cesniene
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Marta Monika Janusaite
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Arturas Vinikovas
- Nephrology and Kidney Transplantation Unit, Nephrology Center, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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24
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Helten C, Mourikis P, Dannenberg L, M'Pembele R, Trojovsky K, Ayhan A, Kohlmorgen C, Grandoch M, Levkau B, Veulemans V, Petzold T, Hohlfeld T, Kelm M, Zeus T, Polzin A. A novel mechanism of ACE inhibition-associated enhanced platelet reactivity: disproof of the ARB-MI paradox? Eur J Clin Pharmacol 2020; 76:1245-1251. [PMID: 32500252 DOI: 10.1007/s00228-020-02915-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/25/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE ACE inhibitors (ACEI) and angiotensin II receptor blockers (ARB) are important drugs in cardiovascular disease. However, little is known about which of these drug class is to be preferred. First analyses show that the blockade of the renin-angiotensin-aldosterone system (RAAS) influences platelet reactivity. Therefore, we evaluated the effects of ACEI and ARB on platelet reactivity and thrombin generation. METHODS We conducted a time series analysis in 34 patients. We performed light transmission aggregometry (LTA) to evaluate platelet reactivity. Results are given as maximum of aggregation (MoA). Thrombin generation was measured as endogenous thrombin potential (ETP) via calibrated automated thrombogram. Flow cytometry was used to analyze protease-activated receptor (PAR)-1 expression. RESULTS ACEI treatment significantly increased platelet reactivity already 4 h after initiation of treatment (prior vs. 4 h post ACEI: MoA 41.9 ± 16.2% vs. 55.2 ± 16.7%; p = 0.003). After switching from ACEI to ARB treatment, platelet reactivity decreased significantly (3 months after switching: MoA 34.7 ± 20.9%; p = 0.03). ACEI reduced endogenous thrombin potential significantly from before to 3 months after ACEI (ETP 1527 ± 437 nM × min vs. 1088 ± 631 nM × min; p = 0.025). Platelet thrombin receptor (PAR1) expression increased from 37.38 ± 10.97% before to 49.53 ± 6.04% after ACEI treatment (p = 0.036). CONCLUSION ACEI enhanced platelet reactivity. This can be reversed by changing to ARB. The mechanism behind RAAS influencing platelet function seems to be associated with PAR-1 expression.
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Affiliation(s)
- Carolin Helten
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Philipp Mourikis
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - René M'Pembele
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Kajetan Trojovsky
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Aysel Ayhan
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Christina Kohlmorgen
- Institute of Pharmacology and Clinical Pharmacology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maria Grandoch
- Institute of Pharmacology and Clinical Pharmacology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Bodo Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany.,Institute of Molecular Medicine III, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Tobias Petzold
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Thomas Hohlfeld
- Institute of Pharmacology and Clinical Pharmacology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Düsseldorf, Düsseldorf, Germany. .,Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.
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25
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Busch L, Stern M, Dannenberg L, Mourikis P, Gröne M, Özaslan G, Heinen Y, Heiss C, Sansone R, Polzin A, Kelm M. Impact of high on-treatment platelet reactivity after angioplasty in patients with peripheral arterial disease. Platelets 2020; 32:391-397. [PMID: 32252582 DOI: 10.1080/09537104.2020.1742314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: High on-treatment platelet reactivity (HTPR) to dual antiplatelet therapy (DAPT) predicts adverse events in coronary artery disease patients. In peripheral artery disease (PAD) patients, data concerning the clinical impact of HTPR are limited. Therefore, we evaluated the incidence of (i) HTPR to DAPT and (ii) its impact on 6 months outcome after angioplasty.Methods and results: In this prospective single center analysis, we investigated 102 consecutive patients with PAD from 2016 to 2017. All patients underwent peripheral endovascular treatment due to intermittent claudication (Fontaine IIb). Clopidogrel effects were measured using vasodilator-stimulated protein phosphorylation (VASP) assay, aspirin effects by light-transmission aggregometry (LTA). Major adverse limb events (MALE), major adverse cardiac and cerebrovascular events (MACCE) and BARC bleeding (bleeding academic research consortium classification) within 6 months were assessed. HTPR to clopidogrel (n = 37, 36%), to aspirin (n = 11, 11%) and to both (n = 11, 11%) were frequent. Compared to sufficient platelet inhibition by aspirin and clopidogrel (n = 43, 42%), patients with dual HTPR showed a higher risk of MALE at 6 months (27% vs. 7%; hazard ratio [HR]: 4.45; 95% confidence interval [CI]: 1.1 to 67.8; p = .03). This was independent of diabetes, creatinine, body mass index, and age as well as of procedural details in a multivariate logistic regression analysis. MACCE (n = 2) and BARC bleeding rates (n = 2) were low.Conclusion: In this small exploratory study, HTPR was frequent in PAD patients. Furthermore, the results are suggestive that MALE might be associated with dual HTPR. This leads to the hypothesis that optimized antithrombotic regimens post percutaneous transluminal angioplasty should be tested in clinical trials.
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Affiliation(s)
- Lucas Busch
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Manuel Stern
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Lisa Dannenberg
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Philipp Mourikis
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Michael Gröne
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Göksen Özaslan
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Yvonne Heinen
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Christian Heiss
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Roberto Sansone
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Amin Polzin
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Malte Kelm
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
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26
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Shropshire S, Johnson T, Olver C. Platelet aggregometry testing during aspirin or clopidogrel treatment and measurement of clopidogrel metabolite concentrations in dogs with protein-losing nephropathy. J Vet Intern Med 2020; 34:710-718. [PMID: 31981378 PMCID: PMC7096639 DOI: 10.1111/jvim.15694] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 12/19/2019] [Indexed: 12/22/2022] Open
Abstract
Background Dogs with protein‐losing nephropathy (PLN) are treated with antiplatelet drugs for thromboprophylaxis but no standardized method exists to measure drug response. It is also unknown if clopidogrel metabolite concentrations [CM] differ between healthy and PLN dogs. Objectives Assess response to aspirin or clopidogrel in PLN dogs using platelet aggregometry (PA) and compare [CM] between healthy and PLN dogs. Animals Six healthy and 14 PLN dogs. Methods Platelet aggregometry using adenosine diphosphate (ADP), arachidonic acid (AA), and saline was performed in healthy dogs at baseline and 1‐week postclopidogrel administration to identify responders or nonresponders. A decrease of ≥60% for ADP or ≥30% for AA at 1 or 3 hours postpill was used to define a responder. At 1 and 3 hours postclopidogrel, [CM] and PA were measured in healthy and PLN dogs. Platelet aggregometry was performed in PLN dogs at baseline, 1, 6, and 12 weeks after clopidogrel or aspirin administration. Results In PLN dogs receiving clopidogrel, PA differed from baseline at all time points for ADP but not for AA at any time point. Most dogs responded at 1 or both time points except for 1 dog that showed no response. For PLN dogs receiving aspirin, no differences from baseline were observed at any time point for either ADP or AA. No differences in [CM] were found at either time point between healthy and PLN dogs. Conclusions and Clinical Importance Platelet aggregometry may represent an objective method to evaluate response to clopidogrel or aspirin treatment and PLN dogs appear to metabolize clopidogrel similarly to healthy dogs.
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Affiliation(s)
- Sarah Shropshire
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
| | - Tyler Johnson
- North Carolina State University, Raleigh, North Carolina
| | - Christine Olver
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
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27
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Platelet Reactivity in Patients on Aspirin and Clopidogrel Therapy Measured by a New Bedside Whole-Blood Assay. J Cardiovasc Pharmacol 2020; 73:40-47. [PMID: 30383606 DOI: 10.1097/fjc.0000000000000631] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Various tests are available for measuring on-treatment platelet reactivity. The pharmacologically most specific assays are time-consuming and elaborate. A highly specific and convenient assay would be desirable for clinical routine. In this pilot study, we aimed to examine the ability of a novel bedside whole-blood assay-ROTEM platelet-to evaluate platelet inhibition compared with established assays. Platelet reactivity was investigated in 93 patients. Forty-Seven patients were on permanent aspirin therapy and 46 on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. We used ROTEM platelet impedance aggregometry (ROTEM-PTL), light transmission aggregometry (LTA), Multiplate electrode aggregometry (MEA) and vasodilator-stimulated phosphoprotein flow cytometry. Receiver operating characteristic (ROC) analyses showed ROTEM-PTL differentiates well between patients on medication and healthy individuals: aspirin: ROCAUC 0.99 (95% confidence interval, 0.97-1.01); P < 0.0001; DAPT treatment: ROCAUC 0.80 (95% confidence interval, 0.69-0.91); P < 0.001. Pearson regression analyses showed moderate correlations between assays. Aspirin: MEA versus ROTEM-PTL r = 0.435, P ≤ 0.001; LTA versus ROTEM-PTL r = 0.048, P = 0.180. DAPT: MEA versus ROTEM-PTL r = 0.398, P = 0.001; LTA versus ROTEM-PTL r = 0.409, P = 0.001; vasodilator-stimulated phosphoprotein versus ROTEM-PTL r = 0.164, P = 0.055. ROTEM platelet distinguished well between treated and healthy individuals but correlated moderately with other assays. Clinical trials are needed to investigate the ability of this new assay to identify patients at risk of adverse events.
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28
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Aspirin antiplatelet effects are associated with body weight. Vascul Pharmacol 2019; 125-126:106635. [PMID: 31862488 DOI: 10.1016/j.vph.2019.106635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/01/2019] [Accepted: 12/17/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aspirin is indispensable in secondary prevention of ischemic events. Recently, it was reported that clinical aspirin effects are hampered in patients above 70 kg body weight. It is well known that a plethora of reasons beside obesity is associated with increased platelet reactivity and insufficient aspirin effects (HTPR). However, data regarding an association between pharmacodynamic response to aspirin and body weight are missing. METHODS In this pilot study, we included 59 patients from University Hospital Duesseldorf. Impedance aggregometry was used to assess pharmacodynamic response to aspirin. RESULTS AA-induced platelet reactivity was significantly higher in patients above 70 kg (<70 kg: 28.27 ± 26.33 vs. >70 kg: 45.93 ± 27.1, p = .035) and correlated well with the bodyweight of patients in this study (r = 0.33, R2 = 0.09, p = .016). According to this, insufficient pharmacodynamic response (HTPR) to aspirin was significantly more frequent in patients over 70 kg (<70 kg: 25% vs. >70 kg: 43%, p = .035). CONCLUSION Insufficient pharmacodynamic response to aspirin is associated with body weight. This finding may play a role in the impaired clinical efficacy of aspirin in patients >70 kg. An optimal aspirin regime in these patients needs to be evaluated in large scale trials.
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29
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Prevention and treatment of stroke in patients with chronic kidney disease: an overview of evidence and current guidelines. Kidney Int 2019; 97:266-278. [PMID: 31866114 DOI: 10.1016/j.kint.2019.09.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/06/2019] [Accepted: 09/26/2019] [Indexed: 12/17/2022]
Abstract
Chronic kidney disease is strongly associated with an increased risk of stroke, small vessel disease, and vascular dementia. Common vascular factors for stroke, such as hypertension, diabetes, and atrial fibrillation, are more prevalent in patients with chronic kidney disease, accounting for this association. However, factors unique to these patients, such as uremia, oxidative stress, and mineral and bone abnormalities, as well as dialysis-related factors are also believed to contribute to risk. Despite improvements in stroke treatment and survival in the general population, the rate of improvement in patients with chronic kidney disease, especially those who are dialysis dependent, has lagged behind. There is a lack of or conflicting evidence that those with renal disease, particularly when advanced or older, consistently derive benefit from currently available preventive and therapeutic interventions for stroke in the general population. In this review, we explore the complexities and challenges of these interventions in the population with renal disease.
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30
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Leiva O, Bekendam RH, Garcia BD, Thompson C, Cantor A, Chitalia V, Ravid K. Emerging Factors Implicated in Fibrotic Organ-Associated Thrombosis: The Case of Two Organs. TH OPEN 2019; 3:e165-e170. [PMID: 31259299 PMCID: PMC6598088 DOI: 10.1055/s-0039-1692204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022] Open
Abstract
Thrombosis is at the heart of cardiovascular complications observed in specific diseases. A heightened thrombosis risk above that in general population in diseases such as myelofibrosis and chronic kidney disease implicates disease-specific mediators of thrombosis. This relative lack of information regarding the mechanisms of thrombosis in specific organ pathologies hitherto has remained limited. Evolving literature implicates some soluble factors in the blood of patients with discrete disorders, inflicting fundamental changes in the components of thrombosis. In this era of precision medicine, integrating these disease-specific factors in a comprehensive thrombotic risk assessment of patients is imperative in guiding therapeutic decisions. A complex network of mechanisms regulates each organ pathology and resultant thrombotic phenotypes. This review surveys different effectors of thrombogenicity associated with two pathologically fibrotic organs used as model systems, the bone marrow and kidney, as well as focuses attention to a common inducer of fibrosis and thrombosis, lysyl oxidase.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Roelof H Bekendam
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Brenda D Garcia
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Medicine, Mount Auburn Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Cristal Thompson
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Alan Cantor
- Children's Hospital Boston, Boston, Massachusetts, United States
| | - Vipul Chitalia
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, United States.,VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Katya Ravid
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, United States
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31
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Dannenberg L, Mourikis P, Naguib D, Zako S, Helten C, M'Pembele R, Trojovsky K, Konsek D, Wolff G, Brockmeyer M, Schulze V, Levkau B, Hohlfeld T, Zeus T, Kelm M, Polzin A. Antiplatelet effects of aspirin and clopidogrel after left atrial appendage (LAA) occluder implantation. Int J Cardiol 2019; 275:95-100. [DOI: 10.1016/j.ijcard.2018.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 12/20/2022]
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32
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Zhu P, Tang XF, Xu JJ, Song Y, Liu R, Zhang Y, Gao L, Gao Z, Chen J, Yang YJ, Gao RL, Xu B, Yuan JQ. Platelet reactivity in patients with chronic kidney disease undergoing percutaneous coronary intervention. Platelets 2018; 30:901-907. [PMID: 30518271 DOI: 10.1080/09537104.2018.1549319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study aimed to evaluate the platelet reactivity in real-world patients with different chronic kidney disease (CKD) stages after percutaneous coronary intervention (PCI), and to examine whether high residual platelet reactivity (HRPR) is associated with higher incidence of adverse cardiovascular events in a 2-year follow up. A total of 10 724 consecutive patients receiving DAPT with aspirin and clopidogrel after PCI throughout 2013 were enrolled. We applied modified thromboelastography (mTEG) in 6745 patients. Kaplan-Meier analysis and Cox proportional regression analysis were applied to illustrate end points for patients. The prevalence of HRPR for adenosine diphosphate (ADP) was higher in patients with CKD3-5 than patients with CKD1-2 (47.0% vs. 37.3%, p = 0.002), but not for arachidonic acid (AA). No significant difference was observed for MACCE between patients with or without HRPR for ADP (HR 1.004, 95%CI: 0.864-1.167, p = 0.954). Patients with HRPR for ADP was associated with less bleeding events than patients without HRPR for ADP (HR 0.795, 95%CI: 0.643-0.982, p = 0.034). In this large cohort of real-world patients after PCI, the deterioration of renal function was linked to HRPR for ADP. HRPR was not associated with MACCE in patients with CKD in a 2-year follow up. Bleeding risks were significantly lower in PCI patients with versus without HRPR for ADP.
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Affiliation(s)
- Pei Zhu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Xiao-Fang Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jing-Jing Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ying Song
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ru Liu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yin Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Lijian Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Zhan Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jue Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yue-Jin Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Run-Lin Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Bo Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jin-Qing Yuan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, The Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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Dannenberg L, Petzold T, Achilles A, Naguib D, Zako S, Helten C, M'Pembele R, Mourikis P, Podsvyadek Y, Grandoch M, Levkau B, Zeus T, Kelm M, Hohlfeld T, Polzin A. Dose reduction, oral application, and order of intake to preserve aspirin antiplatelet effects in dipyrone co-medicated chronic artery disease patients. Eur J Clin Pharmacol 2018; 75:13-20. [PMID: 30251061 DOI: 10.1007/s00228-018-2560-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/17/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Dipyrone comedication in aspirin-treated patients is associated with impaired pharmacodynamic response to aspirin (high on-treatment platelet reactivity [HTPR]). Additionally, in small observational studies, an association with impaired outcome has been described. In this uncontrolled, hypothesis-generating study, we aimed to investigate strategies to prevent this drug-drug interaction in patients with coronary artery disease (CAD). METHODS We analyzed pharmacodynamic response to aspirin in 80 dipyrone co-medicated CAD patients. Aspirin antiplatelet effects were measured using arachidonic acid (AA)-induced light-transmission aggregometry (LTA). Platelet reactivity was associated with daily dose, administration form, and frequency. Additionally, we conducted a time-series analysis in patients with HTPR to aspirin with re-evaluation of pharmacodynamic response to aspirin after 5 days. RESULTS Patients' mean age was 75.5 ± 9.8 years. Forty-three (54%) were male, 22 (27.5%) obese, and 38 (47.5%) diabetics. Baseline characteristics, cardiovascular risk factors, comorbidities, comedication, or laboratory parameters did not differ between patients with or without HTPR. HTPR to aspirin occurred in 34 out of 80 patients (42.5%). The incidence of HTPR was associated with dipyrone daily dose (< 1 g/day: HTPR 20% vs. > 3 g/day: HTPR 50%, p > 0.0001) and form of administration (i.v. 87.5% vs. oral 37.5%; p < 0.0001). A strict order of intake (aspirin 30 min prior to dipyrone) restored aspirin antiplatelet effects in all patients (HTPR before 100% vs. HTPR after 0%, p = 0.0002). CONCLUSION This study shows that dipyrone should be used with caution in aspirin-treated patients. If dipyrone seems indispensable, the lowest effective dose and a strict order of intake seem favorable.
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Affiliation(s)
- Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany.
| | - Tobias Petzold
- Department of Cardiology, LMU München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
| | - Alina Achilles
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - David Naguib
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - Saif Zako
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - Carolin Helten
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - René M'Pembele
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - Philipp Mourikis
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - Yanina Podsvyadek
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Düsseldorf, Germany
| | - Maria Grandoch
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Düsseldorf, Germany
| | - Bodo Levkau
- West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Institute of Pathophysiology, Essen, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
| | - Thomas Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Düsseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Düsseldorf, Germany
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Covic A, Genovesi S, Rossignol P, Kalra PA, Ortiz A, Banach M, Burlacu A. Practical issues in clinical scenarios involving CKD patients requiring antithrombotic therapy in light of the 2017 ESC guideline recommendations. BMC Med 2018; 16:158. [PMID: 30227855 PMCID: PMC6145111 DOI: 10.1186/s12916-018-1145-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/03/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The choice of the most appropriate antithrombotic regimen that balances ischemic and bleeding risks was addressed by the August 2017 European Society of Cardiologists (ESC)/European Association for Cardio-Thoracic Surgery Focused Update recommendations, which propose new evaluation scores and protocols for patients requiring a coronary stent or patients with an acute coronary syndrome, atrial fibrillation, or a high bleeding risk and indication for oral anticoagulation therapy. DISCUSSION Numerous questions remain regarding antithrombotic regimens and risk management algorithms for both ischemic and hemorrhagic events in patients with chronic kidney disease (CKD) in various clinical scenarios. Limitations of current studies include a general ack of advanced CKD patients in major randomized controlled trials, of evidence on algorithm implementation, and of robust assessment tools for hemorrhagic risk. Herein, we aim to analyze the ESC Update recommendations and the newly implemented risk scores (DAPT, PRECISE-DAPT, PARIS) from the point of view of CKD, providing suggestions on drug choice (which combination has the best evidence), dosage, and duration (the same or different as for non-CKD population) of antithrombotics, as well as to identify current shortcomings and to envision directions of future research. CONCLUSION We provide an evidence-based perspective on the new proposed bleeding management protocol, with focus on the CKD population. Despite previous important steps on antithrombotic therapy of renal patients, there remain many unsolved questions for which our suggestions could fundament new randomized controlled trials and specific protocols.
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Affiliation(s)
- Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital, Iasi, Romania.,'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Inserm U1116, CHRU Nancy, Nancy, France.,Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Philip A Kalra
- The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, 'Grigore T. Popa' University of Medicine, Iasi, Romania.
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Chen HY, Chou P. Associations Between PFA-Measured Aspirin Resistance, Platelet Count, Renal Function, and Angiotensin Receptor Blockers. Clin Appl Thromb Hemost 2018; 24:63S-68S. [PMID: 29996660 PMCID: PMC6714849 DOI: 10.1177/1076029618786588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Aspirin resistance is used to describe patients who are undergoing aspirin therapy but fail for the inhibition of thromboxane biosynthesis in platelets. Although the true mechanism is unclear, drug–drug interaction remains a possible factor. The study aimed to determine whether there was association between aspirin resistance and the concomitant cardiovascular medication. Using the Platelet Function Analyzer-100 system, aspirin resistance was evaluated in aspirin-treated patients from the outpatient department. The associations between aspirin resistance and their concomitant common cardiovascular medication were analyzed. Aspirin resistance was prevalent in 147 (17.7%) of 831 patients. Concomitant angiotensin receptor blocker (ARB) treatment and low platelet count were associated with aspirin response (P = .04, .02, respectively). Multivariate logistic regression analysis results showed an association between aspirin response and ARB therapy (adjusted odds ratio [OR] 1.48; 95% confidence interval, CI: 1.08-2.18). And the association was blunted when platelet count was considered (adjusted OR 1.43, 95% CI: 0.92-2.23). In ARB-treated patients, increased creatinine and decreased hematocrit laboratory data increased the risk of aspirin resistance (P = .02, .04, respectively), and the effect of platelet count on aspirin resistance was diminished by ARB therapy. Concomitant ARB treatment in aspirin-treated patients decreased the risk of aspirin resistance, and the effect was dependent on low platelet count. In ARB-treated patients, increased creatinine and decreased hematocrit data increased the risk of aspirin resistance. In addition, the effect of platelet count on aspirin resistance was diminished by ARB treatment.
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Affiliation(s)
- Hung Yi Chen
- Division of Cardiology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Pesus Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
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36
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Mathew RO, Gosmanova EO, Sidhu MS. Targeting Cardiovascular Disease in Patients with Chronic Kidney Disease: Is Primary Prevention with Aspirin Ready for Prime Time? : Editorial to: "Aspirin for Primary Prevention of Cardiovascular Disease and Renal Disease Progression in Chronic Kidney Disease Patients: A Multicenter Randomized Clinical Trial (AASER Study)" by M. Goicoechea et al. Cardiovasc Drugs Ther 2018; 32:241-243. [PMID: 29923131 DOI: 10.1007/s10557-018-6803-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Roy O Mathew
- Department of Medicine, Division of Nephrology, William Jennings Bryan Dorn VAMC, Columbia, SC, USA
| | - Elvira O Gosmanova
- Nephrology Section, Stratton VA Medical Center and Division of Nephrology, Department of Medicine, Albany Medical College, Albany, NY, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Albany Medical Center and Department of Medicine, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA.
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37
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Helten C, Naguib D, Dannenberg L, Pöhl M, Ayhan A, Hohlfeld T, Levkau B, Kelm M, Zeus T, Polzin A. Platelet function testing: dead or alive. J Thromb Haemost 2018; 16:984-986. [PMID: 29512292 DOI: 10.1111/jth.13997] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 12/17/2022]
Abstract
Essentials Pharmacodynamic response to antiplatelet medication is heterogeneous. Platelet reactivity to dual antiplatelet therapy was analyzed by three platelet function assays. The prevalence of high and low platelet reactivity differed significantly between assays. Future trials are needed to determine the best assay to analyze platelet function. SUMMARY Background High on-treatment platelet reactivity (HTPR) to antiplatelet medication leads to ischemic events, whereas low on-treatment platelet reactivity (LTPR) increases bleeding risk. However, various trials have failed to demonstrate superiority of tailored antiplatelet regimens (ARCTIC, ANTARCTIC, Trigger-PCI, and GRAVITAS). TROPICAL-ACS was the first study that demonstrated the benefit of tailoring antiplatelet medication according to platelet function analysis. A potential reason may be that different platelet function assays were used in these trials. Objectives To evaluate whether the results of platelet function tests are comparable. Patients/Methods We tested three commonly used assays - light transmission aggregometry (LTA), (Multiplate impedance aggregometry [MP]), and vasodilator-stimulated phosphoprotein phosphorylation assay (VASP) - in 23 patients receiving dual antiplatelet therapy with aspirin and clopidogrel. Results With LTA, HTPR occurred in 57% of patients; with VASP, it occurred in 43% of patients; and with MP, it occurred in 13% of patients. According to LTA, only 35% of patients were in the therapeutic window; according to VASP, 57% of patients were in the therapeutic window; and according to MP, 48% of patients were in the therapeutic window. With LTA, LTPR occurred in 9% of patients; with VASP, it occurred in 0% of patients; and with MP, it occurred in 39% of patients. Therefore, the prevalences of HTPR and LTPR differed significantly between assays. Remarkably, in 17% of patients, one assay showed HTPR whereas another showed LTPR. Conclusions The results of different platelet function assays differ substantially. Up to now, only TROPICAL-ACS had demonstrated a benefit of tailoring antiplatelet medication according to platelet function analysis. Future trials are needed to evaluate whether the platelet function assay used in TROPICAL-ACS is the 'correct' one and revives platelet function testing.
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Affiliation(s)
- C Helten
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - D Naguib
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - L Dannenberg
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - M Pöhl
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - A Ayhan
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - T Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Düsseldorf, Germany
| | - B Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - M Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - T Zeus
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
| | - A Polzin
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, University Hospital Düsseldorf, Cardiovascular Research Institute Düsseldorf (CARID), Dusseldorf, Germany
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38
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Kennedy C, Wong L, Sexton DJ, Cowman J, Oglesby I, Kenny M, Conlon PJ, Kenny D. Successful kidney transplantation normalizes platelet function. Clin Kidney J 2018; 11:574-580. [PMID: 30087773 PMCID: PMC6070122 DOI: 10.1093/ckj/sfx148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/27/2017] [Indexed: 12/23/2022] Open
Abstract
Background Uraemic platelet dysfunction is not completely understood, in part due to non-physiological platelet function assays. We have developed a physiological flow-based assay that quantifies platelet function in microlitre volumes of blood under arterial shear. The aim of this study was to characterize platelet function before and after kidney transplantation. Methods Ten patients scheduled for living donor kidney transplant surgery and nine healthy controls were analysed using the assay. The motional parameters of platelet behaviour on von Willebrand factor (VWF) were recorded using customized platelet tracking software. The assay was repeated 3–8 weeks post-transplant in the transplant group and at an interval of >3 weeks in normal healthy volunteers. Results Platelet–VWF interactions were markedly reduced in the 10 pre-transplant patients compared with the healthy controls. In seven patients with immediate graft function, dynamic platelet function returned to normal (despite a small decrease in haemoglobin and haematocrit), but remained markedly abnormal in the three patients with delayed graft function (DGF). Conclusions Dynamic platelet function returned to normal following transplantation in those with immediate graft function. This early improvement was not observed in those with DGF. There may be important clinical implications, as patients with DGF are more likely to undergo invasive procedures, including transplant biopsies and insertion of central venous catheters.
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Affiliation(s)
- Claire Kennedy
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Limy Wong
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Donal J Sexton
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Jonathan Cowman
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland.,Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Irene Oglesby
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Martin Kenny
- Department of Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Peter J Conlon
- Department of Nephrology, Beaumont Hospital, Dublin, Ireland.,Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dermot Kenny
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.,Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
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Hartinger J, Novotny R, Bilkova J, Kvasnicka T, Mitas P, Sima M, Hlubocky J, Kvasnicka J, Slanar O, Lindner J. Role of Dipyrone in the High On-Treatment Platelet Reactivity amongst Acetylsalicylic Acid-Treated Patients Undergoing Peripheral Artery Revascularisation. Med Princ Pract 2018; 27:356-361. [PMID: 29754149 PMCID: PMC6167732 DOI: 10.1159/000489970] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 05/13/2018] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To evaluate the effects of dipyrone on sensitivity to aspirin (acetylsalicylic acid [ASA]) in patients who underwent peripheral artery vascular reconstruction. SUBJECTS AND METHODS Impedance aggregometry and light transmission aggregometry were used to determine the effects of dipyrone on ASA treatment in 21 patients. Blood samples were drawn in a 7-day period after the surgery. The cut-off value for high on-treatment platelet reactivity (HTPR) was set at < 65% of aggregation inhibition for impedance aggregometry. For light transmission aggregometry the cut-off value for arachidonic acid-induced aggregation was set at > 20% of aggregating platelets, and the cut-off value for epinephrine-induced aggregation was > 44% of aggregating platelets. The cut-off value for each method was derived from a large number of patients treated with a daily dose of 100 mg of ASA. RESULTS We found HTPR in 14 (67%) of the 21 patients. None had primary resistance to ASA, i.e., after the addition of ASA in vitro all samples showed antiplatelet efficacy. Regression analysis showed a possible correlation between lower efficacy of ASA treatment and higher daily doses of dipyrone (p = 0.005 for impedance aggregometry, p = 0.04 for light transmission aggregometry), higher platelet count (p = 0.005 for impedance aggregometry), and shorter time from surgery (p = 0.03 for impedance aggregometry). CONCLUSION HTPR occurs in 67% of ASA-treated patients after lower limb vascular surgery. The occurrence of HTPR correlates with the daily dose of dipyrone. Therefore, dipyrone should not be used as a postoperative analgesic in ASA-treated patients after peripheral artery revascularisation due to its influence on the effectiveness of ASA.
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Affiliation(s)
- Jan Hartinger
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Robert Novotny
- Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- *Robert Novotny, Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Videnska 1958/9, CZ-140 21 Prague 4 (Czech Republic), E-Mail
| | - Jana Bilkova
- Thrombotic Centre, General University Hospital, Prague, Czech Republic
| | - Tomas Kvasnicka
- Thrombotic Centre, General University Hospital, Prague, Czech Republic
| | - Petr Mitas
- 2nd Department of Cardiovascular Surgery, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Martin Sima
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jaroslav Hlubocky
- 2nd Department of Cardiovascular Surgery, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jan Kvasnicka
- Thrombotic Centre, General University Hospital, Prague, Czech Republic
| | - Ondrej Slanar
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jaroslav Lindner
- 2nd Department of Cardiovascular Surgery, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Burlacu A, Genovesi S, Goldsmith D, Rossignol P, Ortiz A, Kalra PA, Małyszko J, Banach M, Kanbay M, Covic A. Bleeding in advanced CKD patients on antithrombotic medication - A critical appraisal. Pharmacol Res 2017; 129:535-543. [PMID: 29208494 DOI: 10.1016/j.phrs.2017.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 01/16/2023]
Abstract
Patients with advanced chronic kidney disease (CKD) are at an increased risk of bleeding, especially in the context of the complex therapeutic schemes of coronary artery disease (CAD) (from stable angina to acute coronary syndromes), atrial fibrillation or venous thromboembolism. The bleeding issue increases morbidity and mortality, a serious problem in daily medical practice. However, these patients are largely excluded from major randomized clinical trials, which results in the lack of medical evidence-based foundation for specific recommendations regarding antithrombotic treatment in a high bleeding risk setting. Within this framework, the clinician does not benefit from a clear set of algorithms and measures in the exploration and balancing of bleeding and thrombosis risks. We discuss a diversity of scenarios, encompassing all categories of advanced CKD patients with CAD or/and atrial fibrillation, and with various combinations of drugs, such as antiplatelet therapy or/and oral anticoagulation. Our review highlights the most recent research as well as existing gaps in the recommendations of European Society of Cardiology Guidelines. We evaluate the existence or lack of assessment tools for the bleeding risk, strength, reliability and usefulness of the bleeding risk scores. Also, we identify all the measures recommended after risk evaluation, including specific plans, dose adjustments and particular therapeutic approaches. Finally, we provide with suggestions for improving the management of this patient population.
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology - Cardiovascular Diseases Institute, and 'Grigore T. Popa' University of Medicine, Iasi, Romania, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milan Bicocca and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - David Goldsmith
- Renal, Dialysis and Transplantation Unit, Guy's and St Thomas' Hospital, London, UK
| | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Inserm U1116, CHRU Nancy, Université de Lorraine, Association Lorraine de Traitement de l'Insuffisance Rénale (ALTIR) and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Philip A Kalra
- The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Stott Lane, Salford, United Kingdom
| | | | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland.
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center - 'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
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41
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Chen HY, Chou P. PFA-100-measured aspirin resistance is the predominant risk factor for hospitalized cardiovascular events in aspirin-treated patients: A 5-year cohort study. J Clin Pharm Ther 2017; 43:249-255. [PMID: 29055181 DOI: 10.1111/jcpt.12643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/02/2017] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Aspirin therapy is the clinical gold standard for the prevention of cardiovascular events. However, cardiovascular events still develop in some patients undergoing aspirin therapy. Many laboratory methods exist for measuring aspirin resistance. Using the platelet Function Analyzer (PFA)-100 system, we aimed to determine the effect of aspirin resistance on hospitalized cardiovascular events (hCVE) in a 5-year follow-up cohort. We also sought to determine the impact of aspirin resistance on the relationship between common cardiovascular risk factors and cardiovascular hospitalization. METHOD Aspirin resistance was evaluated in aspirin-treated patients from the outpatient department. A total of 465 patients during a 5-year follow-up period were included in this study. The primary endpoint of the study was hospitalization for any acute cardiovascular event. The prevalence and associated risk factors of acute cardiovascular events were evaluated. RESULTS AND DISCUSSION Aspirin resistance was prevalent in 91 (20.0%) of 465 patients. Prior hospitalization history of cardiovascular events was highly associated with aspirin resistance (P = .001). At the 5-year follow-up, cardiovascular events were found to have developed in 11 patients (8 stroke and 3 myocardial infarction) who exhibited aspirin resistance (12.1%) and in 9 (4 stroke and 5 myocardial infarction) patients who did not exhibit aspirin resistance (2.4%) (P < .001). At the 5-year follow-up, multivariate logistic regression analysis results showed a strong association between aspirin resistance and cardiovascular events (adjusted odds ratio 4.28; 95% CI: 1.64-11.20; P = .03). WHAT IS NEW AND CONCLUSION PFA-100 measurements of aspirin resistance correlate with hCVE, as evidenced by both the past medical history and the 5-year follow-up. The logistic regression analysis results showed that aspirin resistance plays a larger role in hospitalized cardiovascular disease than do other cardiovascular risk factors.
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Affiliation(s)
- H Y Chen
- Division of Cardiology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - P Chou
- Institute of Public Health and Community Medicine Research Center, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Mohring A, Piayda K, Dannenberg L, Zako S, Schneider T, Bartkowski K, Levkau B, Zeus T, Kelm M, Hohlfeld T, Polzin A. Thromboxane Formation Assay to Identify High On-Treatment Platelet Reactivity to Aspirin. Pharmacology 2017; 100:127-130. [DOI: 10.1159/000477303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 04/28/2017] [Indexed: 01/29/2023]
Abstract
Platelet inhibition by aspirin is indispensable in the secondary prevention of cardiovascular events. Nevertheless, impaired aspirin antiplatelet effects (high on-treatment platelet reactivity [HTPR]) are frequent. This is associated with an enhanced risk of cardiovascular events. The current gold standard to evaluate platelet hyper-reactivity despite aspirin intake is the light-transmittance aggregometry (LTA). However, pharmacologically, the most specific test is the measurement of arachidonic acid (AA)-induced thromboxane (TX) B2 formation. Currently, the optimal cut-off to define HTPR to aspirin by inhibition of TX formation is not known. Therefore, in this pilot study, we aimed to calculate a TX formation cut-off value to detect HTPR defined by the current gold standard LTA. We measured platelet function in 2,507 samples. AA-induced TX formation by ELISA and AA-induced LTA were used to measure aspirin antiplatelet effects. TX formation correlated nonlinearly with the maximum of aggregation in the AA-induced LTA (Spearman's rho R = 0.7396; 95% CI 0.7208-0.7573, p < 0.0001). Receiver operating characteristic analysis and Youden's J statistics revealed 209.8 ng/mL as the optimal cut-off value to detect HTPR to aspirin with the TX ELISA (area under the curve: 0.92, p < 0.0001, sensitivity of 82.7%, specificity of 90.3%). In summary, TX formation ELISA is reliable in detecting HTPR to aspirin. The calculated cut-off level needs to be tested in trials with clinical end points.
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Abstract
Oral Antiplatelet Drugs (OAD) have a proven track record in the risk reduction of major cardiovascular events in patients with cardiovascular disease and normal kidney function. However, major gaps exist in our understanding of their effects on thrombosis and bleeding in chronic kidney disease (CKD). Clinical practice guidelines are ambiguous about use of such drugs in CKD patients, because patients with moderate to severe CKD were systematically excluded from clinical trials evaluating the efficacy and safety of OAD. Paradoxically, CKD patients are at high risk of thrombosis and major bleeding events. Thus, choosing the right combination of OAD for cardiovascular protection in these patients is challenging. Patients with CKD exhibit high rates of OAD hyporesponsiveness. It is, therefore, imperative to explore the mechanisms responsible for poor response to OAD in CKD patients in order to use these drugs more safely and effectively. This review explores suggested mechanisms of platelet dysfucntion in CKD patients and the available evidence on the efficacy and safety of oral antiplatelet drugs in patients with renal dysfunction.
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Achilles A, Mohring A, Dannenberg L, Piayda K, Levkau B, Hohlfeld T, Zeus T, Kelm M, Polzin A. Analgesic medication with dipyrone in patients with coronary artery disease: Relation to MACCE. Int J Cardiol 2017; 236:76-81. [PMID: 28262342 DOI: 10.1016/j.ijcard.2017.02.122] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/19/2017] [Accepted: 02/24/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The non-opioid analgesic dipyrone can trigger life-threatening blood formation disorders. However, it is frequently used, as many patients with coronary artery disease (CAD) rely on non-opioid analgesics to relieve pain. In this study, we investigated the incidence of death, myocardial infarction (MI) or stroke in CAD patients with aspirin and dipyrone comedication as compared to aspirin-alone. METHODS We conducted an observational pilot study in 72 CAD patients with aspirin ± dipyrone comedication in the department of cardiology of the University Hospital Düsseldorf. The primary end point was a composite of death, myocardial infarction (MI) or stroke. The secondary end points were the components of the primary end point. The median follow-up period was 3.2years. RESULTS The primary end point occurred 67% of patients in the aspirin+dipyrone group as compared to 31% in the aspirin-alone group (odds ratio [OR] 4.5, 95% confidence interval [CI] 1.7 to 12.3; P=0.0028;). All-cause mortality was significantly higher in the aspirin+dipyrone group (44%) than the aspirin-alone group (22%; OR 2.8, 95% CI 1.01 to 7.8; P=0.049). Ischemic events (MI and stroke) were more frequent in the aspirin+dipyrone group as compared to the aspirin alone group as well (OR 4, 95% CI 1.1 to 14; P=0.03). CONCLUSION In this hypothesis generating pilot analysis, dipyrone medication in aspirin treated coronary artery disease patients is associated with an increased cumulative incidence of death, MI or stroke as well as all-cause mortality and ischemic events. These data have to be confirmed in larger registries and trials. CLINICAL TRIAL REGISTRATION http://clinicaltrials.gov/ct2/show/NCT01402804; Identifier: NCT01402804; Date of registration: July 25, 2011.
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Affiliation(s)
- Alina Achilles
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Annemarie Mohring
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Kerstin Piayda
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Bodo Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas Hohlfeld
- Institute for Pharmacology and Clinical Pharmacology, Heinrich Heine University, Dusseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany.
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Assadi-Schmidt A, Mohring A, Liebsch E, Dannenberg L, Achilles A, Pöhl M, Afzal S, Veulemans V, Horn P, Sansone R, Bönner F, Levkau B, Kelm M, Zeus T, Polzin A. SeQuent Please vs. Pantera Lux drug coated balloon angioplasty in real life: Results from the Düsseldorf DCB registry. Int J Cardiol 2016; 231:68-72. [PMID: 28089147 DOI: 10.1016/j.ijcard.2016.12.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/11/2016] [Accepted: 12/08/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND In-stent restenosis (ISR) is still a major concern in interventional cardiology. Drug coated balloon (DCB) angioplasty has been shown to be a promising option in treatment of ISR. However heterogeneity of different DCBs in suppression of neointimal growth has been described in a porcine model of coronary ISR. Therefore, in this registry analysis, we compared two frequently used paclitaxel eluting DCBs, the SeQuent Please and the Pantera Lux DCB. METHODS 571 patients were treated with DCB angioplasty at the Heinrich-Heine University Düsseldorf between 2009 and 2012. Follow-up was conducted during ambulatory care at our department. Major adverse cardiac events (death, myocardial infarction [MI] and target lesion revascularization) were registered during hospitalization and follow-up. RESULTS Patient characteristics, prior diseases, clinical presentation, ejection fraction, procedural success and lost-for-follow-up did not differ between patients treated with the SeQuent Please and. The Pantera Lux DCB. MACE during hospital course were similar as well (Pantera Lux: 6 patients [1.6%] vs. SeQuent®Please: 3 patients [1.5%], relative risk 1.06, 95% confidence interval 0.3-4.2, P=0.93). Event free survival was significantly longer in patients treated with the Pantera Lux DCB as compared to SeQuent Please DCB (Hazard ratio: 0.65, 95% confidence interval 0.43-0.98; P value of log-rank test: 0.0405). CONCLUSION MACE free survival was longer in Pantera Lux DCB treated patients as compared to SeQuent Please treated patients. This finding has to be confirmed in future clinical trials.
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Affiliation(s)
- Athena Assadi-Schmidt
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Annemarie Mohring
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Eva Liebsch
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Alina Achilles
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Martin Pöhl
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Shazia Afzal
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Roberto Sansone
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Florian Bönner
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Bodo Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, Dusseldorf, Germany.
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Pignatelli P, Pastori D, Bartimoccia S, Menichelli D, Vicario T, Nocella C, Carnevale R, Violi F. Anti Xa oral anticoagulants inhibit in vivo platelet activation by modulating glycoprotein VI shedding. Pharmacol Res 2016; 113:484-489. [PMID: 27693274 DOI: 10.1016/j.phrs.2016.09.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/25/2016] [Accepted: 09/26/2016] [Indexed: 01/26/2023]
Abstract
Anti Xa non-vitamin K oral anticoagulants (anti Xa NOACs) seem to possess antiplatelet effect in vitro, but it is unclear if this occurs also in vivo. Aim of the study was to compare the effect on platelet activation of two anti Xa NOACs, namely apixaban and rivaroxaban, to warfarin, and to investigate the potential underlying mechanism by evaluating soluble glycoprotein GPVI (sGPVI), a protein involved in platelet activation. We performed a cross-sectional including AF patients treated with warfarin (n=30), or apixaban 10mg/day (n=40), or rivaroxaban 20mg/day (n=40). Patients were balanced for sex, age and cardiovascular risk factors. Platelet activation by urinary excretion of 11-dehydro-thromboxane (Tx) B2 and soluble GPVI (sGPVI) were analysed at baseline and after 3 months of treatment. Baseline TxB2 value was 155.2±42.7ng/mg creatinine. The 3 months-variation of urinary excretion of TxB2 was -6.5% with warfarin (p=0.197), -29% with apixaban (p<0.001) and -31% with rivaroxaban (p<0.001). Use of anti Xa NOACs was independently associated to the variation of urinary TxB2 (B: -0.469, p<0.001), after adjustment for clinical characteristics; sGPVI was significantly lower in patients treated with NOACs at 3 months (p<0.001), while only a trend for the warfarin group (p=0.116) was observed. The variation of sGPVI was correlated with that of TxB2 in the NOACs group (Rs: 0.527, p<0.001). In 15 patients (5 per each group) platelet recruitment was significantly lowered at 3 months by NOACs (p<0.001), but not by warfarin. The study provides evidence that anti Xa NOACs significantly inhibit urinary TxB2 excretion compared to warfarin, suggesting that NOACs possess antiplatelet property.
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Affiliation(s)
- Pasquale Pignatelli
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy.
| | - Daniele Pastori
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Simona Bartimoccia
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Danilo Menichelli
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Tommasa Vicario
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Cristina Nocella
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Roberto Carnevale
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy; Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Francesco Violi
- IClinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
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