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Montomoli M, Candía BG, Barrios AA, Bernat EP. Anticoagulation in Chronic Kidney Disease. Drugs 2024:10.1007/s40265-024-02077-6. [PMID: 39120783 DOI: 10.1007/s40265-024-02077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 08/10/2024]
Abstract
The nuanced landscape of anticoagulation therapy in patients with chronic kidney disease (CKD) presents a formidable challenge, intricately balancing the dual hazards of hemorrhage and thrombosis. These patients find themselves in a precarious position, teetering on the edge of these risks due to compromised platelet functionality and systemic disturbances within their coagulation frameworks. The management of such patients necessitates a meticulous approach to dosing adjustments and vigilant monitoring to navigate the perilous waters of anticoagulant therapy. This is especially critical considering the altered pharmacokinetics in CKD, where the clearance of drugs is significantly impeded, heightening the risk of accumulation and adverse effects. In the evolving narrative of anticoagulation therapy, the introduction of direct oral anticoagulants (DOACs) has heralded a new era, offering a glimmer of hope for those navigating the complexities of CKD. These agents, with their promise of easier management and a reduced need for monitoring, have begun to reshape the contours of care, particularly for patients not yet on dialysis. However, this is not without its caveats. The application of DOACs in the context of advanced CKD remains a largely uncharted territory, necessitating a cautious exploration to unearth their true potential and limitations. Moreover, the advent of innovative strategies such as left atrial appendage occlusion (LAAO) underscores the dynamic nature of anticoagulation therapy, potentially offering a tailored solution for those at the intersection of CKD and elevated stroke risk. Yet the journey toward integrating such advancements into standard practice is laden with unanswered questions, demanding rigorous investigation to illuminate their efficacy and safety across the spectrum of kidney disease. In summary, the management of anticoagulation in CKD is a delicate dance, requiring a harmonious blend of precision, caution, and innovation. As we venture further into this complex domain, we must build upon our current understanding, embracing both emerging therapies and the need for ongoing research. Only then can we hope to offer our patients a path that navigates the narrow strait between bleeding and clotting, toward safer and more effective care.
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Affiliation(s)
- Marco Montomoli
- Nephrology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain.
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Zhu YY, Wang WX, Cheuk SK, Feng GR, Li XG, Peng JY, Liu Y, Yu SR, Tang JL, Chow SC, Li JB. A landscape of methodology and implementation of adaptive designs in cancer clinical trials. Crit Rev Oncol Hematol 2024; 200:104402. [PMID: 38848881 DOI: 10.1016/j.critrevonc.2024.104402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The use of adaptive designs in cancer trials has considerably increased worldwide in recent years, along with the release of various guidelines for their application. This systematic review aims to comprehensively summarize the key methodological and executive features of adaptive designs in cancer clinical trials. METHODS A comprehensive search from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted to screen eligible clinical trials that employed adaptive designs and were conducted in cancer patients. The methodological and executive characteristics of adaptive designs were the main measurements extracted. Descriptive analyses, primarily consisting of frequency and percentage, were employed to analyzed and reported the data. RESULTS A total of 180 cancer clinical trials with adaptive designs were identified. The first three most common type of adaptive design was the group sequential design (n=114, 63.3 %), adaptive dose-finding design (n=22, 12.2 %), and adaptive platform design (n=16, 8.9 %). The results showed that 4.4 % (n=8) of trials conducted post hoc modifications, and around 29.4 % (n=53) did not provide the methods for controlling type I errors. Among phase II or above trials, 79.9 % (112/140) applied the surrogate endpoint as the primary outcome in these trials. Importantly, 27.2 % (49/180) of trials did not report clear information on the independent data monitoring committee (iDMC), and 13.3 % (n=24) without clear information on interim analyses. Interim analyses suggested 34.4 % (62/180) of trials being stopped for futility, 10.6 % (n=19) for efficacy, and 2.2 % (n=4) for safety concerns in the early stage. CONCLUSIONS This study emphasizes adaptive designs in cancer trials face significant challenges in their design or strict implementation according to protocol, which might significantly compromise the validity and integrity of trials. It is thus important for researchers, sponsors, and policymakers to actively oversee and guide their application.
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Affiliation(s)
- Ying-Ying Zhu
- Clinical Research Design Division, Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Wen-Xuan Wang
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China; Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Shui-Kit Cheuk
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China; Department of Epidemiology and Health Statistics, School of Public Health, Peking University, Beijing, PR China
| | - Guan-Rui Feng
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Xing-Ge Li
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Jia-Ying Peng
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Ying Liu
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Shao-Rui Yu
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Jin-Ling Tang
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen, PR China
| | - Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA.
| | - Ji-Bin Li
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, PR China.
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Huang Y, Wang J, Guo Y, Shen L, Li Y. Fibrinogen binding to activated platelets and its biomimetic thrombus-targeted thrombolytic strategies. Int J Biol Macromol 2024; 274:133286. [PMID: 38908635 DOI: 10.1016/j.ijbiomac.2024.133286] [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: 11/24/2023] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 06/24/2024]
Abstract
Thrombosis is associated with various fatal arteriovenous syndromes including ischemic stroke, myocardial infarction, and pulmonary embolism. However, current clinical thrombolytic treatment strategies still have many problems in targeting and safety to meet the thrombolytic therapy needs. Understanding the molecular mechanism that underlies thrombosis is critical in developing effective thrombolytic strategies. It is well known that platelets play a central role in thrombosis and the binding of fibrinogen to activated platelets is a common pathway in the process of clot formation. Based on this, a concept of biomimetic thrombus-targeted thrombolytic strategy inspired from fibrinogen binding to activated platelets in thrombosis was proposed, which could selectively bind to activated platelets at a thrombus site, thus enabling targeted delivery and local release of thrombolytic agents for effective thrombolysis. In this review, we first summarized the main characteristics of platelets and fibrinogen, and then introduced the classical molecular mechanisms of thrombosis, including platelet adhesion, platelet activation and platelet aggregation through the interactions of activated platelets with fibrinogen. In addition, we highlighted the recent advances in biomimetic thrombus-targeted thrombolytic strategies which inspired from fibrinogen binding to activated platelets in thrombosis. The possible future directions and perspectives in this emerging area are briefly discussed.
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Affiliation(s)
- Yu Huang
- Department of Radiology, Shanghai Jiao Tong University School of Medicine Affiliated Shanghai Sixth People's Hospital, 600 Yi Shan Road, Shanghai 200233, PR China.
| | - Jiahua Wang
- Department of Radiology, Shanghai Jiao Tong University School of Medicine Affiliated Shanghai Sixth People's Hospital, 600 Yi Shan Road, Shanghai 200233, PR China
| | - Yuanyuan Guo
- Department of Radiology, Shanghai Jiao Tong University School of Medicine Affiliated Shanghai Sixth People's Hospital, 600 Yi Shan Road, Shanghai 200233, PR China
| | - Lingyue Shen
- Department of Oral & Maxillofacial-Head & Neck Oncology, Department of Laser and Aesthetic Medicine, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stoma-tology & Shanghai Research Institute of Stomatology, 639 Zhizaoju Road, Shanghai 200011, PR China.
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University School of Medicine Affiliated Shanghai Sixth People's Hospital, 600 Yi Shan Road, Shanghai 200233, PR China.
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Hines DM, Doshi R, Anupindi VR, Dai F, Russ C, Stellhorn R, Cheng D, Deeba S, Wang Y, DeKoven M. Payer approval and rejection of oral anticoagulant prescriptions and prescription abandonment patterns among patients with venous thromboembolism. J Manag Care Spec Pharm 2024; 30:441-455. [PMID: 38277234 PMCID: PMC11068657 DOI: 10.18553/jmcp.2024.23194] [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: 01/28/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major public health condition that renders patients at risk of recurrent events, which significantly increases their morbidity, mortality, and health care costs. Apart from warfarin, direct oral anticoagulants, such as apixaban, dabigatran, or rivaroxaban, are approved for VTE treatment. Cardiovascular drugs are largely impacted by formulary restrictions; however, the impact on oral anticoagulants (including warfarin and direct oral anticoagulants) in VTE has not been well studied. OBJECTIVE To describe the extent of payer-rejected claims for oral anticoagulants for VTE and the factors associated with rejected claims. Prescription abandonment of oral anticoagulants and the time to an eventual fill for oral anticoagulant after rejection or abandonment were also evaluated. METHODS A retrospective cohort study was conducted among patients with VTE newly prescribed an oral anticoagulant (first claim was the index) between October 2016 and October 2021. Descriptive statistics were used to describe the proportion of patients with paid (ie, filled), rejected, or abandoned index oral anticoagulant prescription and journey to paid prescription among those with initial rejection. Multivariable logistic regression was used to identify factors associated with initial rejection. RESULTS Among the overall sample (N = 297,312), 74.3% had initial oral anticoagulant prescriptions approved, 9.1% had them rejected, and 16.7% abandoned them. Of the patients with initial rejection, 82.1% eventually filled their oral anticoagulant prescriptions; however, for 14.2% of these patients, the first fill was for an oral anticoagulant other than that initially prescribed. The mean time to a first fill for an oral anticoagulant after an initial rejection was 18.3 days. More than half of the patients with an initial rejected oral anticoagulant claim had at least 1 additional rejection during the follow-up period. Of the patients who abandoned their initial oral anticoagulant prescription, 83.9% filled an oral anticoagulant prescription during follow-up; the mean time to fill for the index oral anticoagulant was 15.6 days. Oral anticoagulant type, Medicare payer coverage, prescribing physician specialty, and VTE diagnosis setting of care were significantly associated with index oral anticoagulant claim rejection (P < 0.05). CONCLUSIONS Rejection and abandonment may delay access to oral anticoagulant treatment. Factors contributing to these scenarios should be understood and addressed for proper VTE management.
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Montero-Balosa MC, Limón-Mora JA, Leal-Atienza A, Luque-Romero LG, Aguado-Romeo MJ, Isabel-Gómez R, Molina-López MT. Effectiveness and safety of oral anticoagulant therapy in a real-world cohort with atrial fibrillation: The SIESTA-A study protocol. PLoS One 2023; 18:e0294822. [PMID: 38019815 PMCID: PMC10686507 DOI: 10.1371/journal.pone.0294822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/08/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Oral anticoagulants (OACs) are first-line drugs for stroke prevention in patients with atrial fibrillation (AF). The introduction of new lines of therapy with direct oral anticoagulants (DOACs) has led to a decreased use of vitamin K antagonists (VKAs). Comparative analyses of DOACs in clinical trials are scarce and the comparator has mostly been warfarin. Their impact on health outcomes in observational studies has not always been consistent. The aim of this study is to evaluate the effectiveness and safety of DOACs and VKAs in patients with AF using Real-World Data (RWD). METHODS AND ANALYSIS Population-based retrospective cohort study using RWD from actual practice. Period: January 2012-December 2020. Inclusion criteria: patients with AF who had not taken OACs in the previous 12 months. Exclusion criteria: <40 years, with severe mitral stenosis, or valvular heart disease or aortic and/or mitral valve procedures. Data source: The Andalusian Population Health Database, Spain. Outcome measures: a) Effectiveness: ischaemic stroke, transient ischaemic attack, systemic and pulmonary embolism, and death; b) Safety: gastrointestinal and intracranial haemorrhaging; Independent variables: age, sex, comorbidities, medication and health resource use, CHA2DS2-VASC, HAS-BLED, and analytical tests. Statistical analysis: crude incidence analysis, survival models, Kaplan-Meier, Cox regression analysis adjusted for possible confounding and paired analysis by propensity score matching.
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Affiliation(s)
- M. C. Montero-Balosa
- Servicio de Farmacia de Atención Primaria, Distrito Aljarafe y Sevilla Norte, Servicio Andaluz de Salud, Sevilla, Spain
| | - J. A. Limón-Mora
- Coordinación de Gestión y Evaluación, Servicio Andaluz de Salud, Sevilla, Spain
| | - A. Leal-Atienza
- Fundación Pública Andaluza para la Gestión de la Investigación en Salud de Sevilla (FISEVI), Consejería de Salud y Consumo, Sevilla, Spain
| | - L. G. Luque-Romero
- Unidad de Investigación, Distrito Aljarafe y Sevilla Norte, Servicio Andaluz de Salud, Sevilla, Spain
| | - M. J. Aguado-Romeo
- Centro de Transfusión de Tejidos y Células de Sevilla, Red Andaluza de Medicina Transfusional de Tejidos y Células, Consejería de Salud y Consumo, Sevilla, Spain
| | - R. Isabel-Gómez
- Agencia de Evaluación de Tecnologías Sanitarias de Andalucía, Consejería de Salud y Consumo, Sevilla, Spain
| | - M. T. Molina-López
- Servicio de Farmacia de Atención Primaria, Distrito Sevilla, Servicio Andaluz de Salud, Sevilla, Spain
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A Contextual-Bandit-Based Approach for Informed Decision-Making in Clinical Trials. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081277. [PMID: 36013456 PMCID: PMC9410371 DOI: 10.3390/life12081277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022]
Abstract
Clinical trials are conducted to evaluate the efficacy of new treatments. Clinical trials involving multiple treatments utilize the randomization of treatment assignments to enable the evaluation of treatment efficacies in an unbiased manner. Such evaluation is performed in post hoc studies that usually use supervised-learning methods that rely on large amounts of data collected in a randomized fashion. That approach often proves to be suboptimal in that some participants may suffer and even die as a result of having not received the most appropriate treatments during the trial. Reinforcement-learning methods improve the situation by making it possible to learn the treatment efficacies dynamically during the course of the trial, and to adapt treatment assignments accordingly. Recent efforts using multi-arm bandits, a type of reinforcement-learning method, have focused on maximizing clinical outcomes for a population that was assumed to be homogeneous. However, those approaches have failed to account for the variability among participants that is becoming increasingly evident as a result of recent clinical-trial-based studies. We present a contextual-bandit-based online treatment optimization algorithm that, in choosing treatments for new participants in the study, takes into account not only the maximization of the clinical outcomes as well as the patient characteristics. We evaluated our algorithm using a real clinical trial dataset from the International Stroke Trial. We simulated the online setting by sequentially going through the data of each participant admitted to the trial. Two bandits (one for each context) were created, with four choices of treatments. For a new participant in the trial, depending on the context, one of the bandits was selected. Then, we took three different approaches to choose a treatment: (a) a random choice (i.e., the strategy currently used in clinical trial settings), (b) a Thompson sampling-based approach, and (c) a UCB-based approach. Success probabilities of each context were calculated separately by considering the participants with the same context. Those estimated outcomes were used to update the prior distributions within the bandit corresponding to the context of each participant. We repeated that process through the end of the trial and recorded the outcomes and the chosen treatments for each approach. We also evaluated a context-free multi-arm-bandit-based approach, using the same dataset, to showcase the benefits of our approach. In the context-free case, we calculated the success probabilities for the Bernoulli sampler using the whole clinical trial dataset in a context-independent manner. The results of our retrospective analysis indicate that the proposed approach performs significantly better than either a random assignment of treatments (the current gold standard) or a multi-arm-bandit-based approach, providing substantial gains in the percentage of participants who are assigned the most suitable treatments. The contextual-bandit and multi-arm bandit approaches provide 72.63% and 64.34% gains, respectively, compared to a random assignment.
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Sharma M, Chaudhary D. In vitro and in vivo implications of rationally designed bromelain laden core-shell hybrid solid lipid nanoparticles for oral administration in thrombosis management. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2022; 42:102543. [PMID: 35189392 DOI: 10.1016/j.nano.2022.102543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
Bromelain, a dietary supplement of cysteine protease family having promising results against thrombosis, is gaining attention. Yet poor mechanical stability, gastric instability, high oral dose and poor patient compliance restricted its clinical application. Therefore, acid stable bromelain loaded hybrid solid lipid nanoparticles (Br-HNPs) were fabricated and characterized for their contribution to in-vivo stability and therapeutic efficacy in thrombosis management. Comprehensive optimization of various process and formulation variables ensued the formation of nano-sized (120.56 ± 40.12 nm) Br-HNPs with entrapment efficiency of 86.32 ± 5.56%. Spherical core shell framework of Br-HNPs prolonged drug release and provided in-vivo and storage stability at room temperature. Br-HNPs significantly inhibited platelet aggregation without affecting bleeding time and dissolved thrombus at 1.91-fold higher efficacy compared to bromelain. Furthermore, Br-HNPs prevented hypercoagulation states and suppressed cytokines production significantly (P < .05) contributing to its antiplatelet activity. These findings indicated that Br-HNPs could serve as a promising alternative to commercial therapies for management of thrombotic disorders.
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Affiliation(s)
- Manu Sharma
- Department of Pharmacy, Banasthali Vidyapith, Banasthali, Rajasthan, India.
| | - Deepika Chaudhary
- Department of Pharmacy, Banasthali Vidyapith, Banasthali, Rajasthan, India.
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Nanocarrier-Based Management of Venous and Arterial Thrombosis. CRYSTALS 2022. [DOI: 10.3390/cryst12040450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Cardiovascular diseases represent the leading cause of mortality worldwide, with recent epidemiological studies revealing an increasing trend of prevalence and incidence globally. Among cardiovascular disorders, both arterial and venous thrombosis and particularly their acute life-threating complications such as ischemic stroke, acute myocardial infarction, deep venous thrombosis and pulmonary embolism are responsible for more than 25% of all deaths worldwide. The modern approach following progresses in anticoagulant, thrombolytic and antiaggregant therapies has significantly improved the prognoses of these conditions in the last past decades. However, several challenges still remain such as achieving the optimal drug concentration at the injured site, reducing the shortcomings of drug resistance and the incidence of life-threatening hemorrhages. Nanomedicine is a well-known field of medicine in which atomic and molecular structures ranging between 0.1–100 nm are used in various domains due to their specific mechanical, electrical, thermal and magnetic properties. Recent experimental and clinical evidence have shown that nanotechnology could be a safe, effective and an appealing approach for various non-cardiovascular and cardiovascular diseases such as thromboembolic conditions. In this review, we have described the most promising nanotechnology-based approaches not only for the diagnosis, but also for the treatment of vascular thrombotic diseases.
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Mencarini T, Roka-Moiia Y, Bozzi S, Redaelli A, Slepian MJ. Electrical impedance vs. light transmission aggregometry: Testing platelet reactivity to antiplatelet drugs using the MICELI POC impedance aggregometer as compared to a commercial predecessor. Thromb Res 2021; 204:66-75. [PMID: 34147831 DOI: 10.1016/j.thromres.2021.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/08/2021] [Accepted: 05/26/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patients' responses to antiplatelet therapy significantly vary, with individuals showing high residual platelet reactivity associated with thrombosis. To personalize thrombosis management, platelet function testing has been suggested as a promising tool able to monitor the antithrombotic effect of antiplatelet agents in real-time. We have prototyped the MICELI, a miniature and easy-to-use electrical impedance aggregometer (EIA), measuring platelet aggregation in whole blood. Here, we tested the capability of the MICELI aggregometer to quantify platelet reactivity on antiplatelet agents, as compared with conventional light-transmission aggregometry (LTA). METHODS Platelet aggregation in ACD-anticoagulated whole blood and platelet-rich plasma of healthy donors (n = 30) was evaluated. The effect of clopidogrel, ticagrelor, cangrelor, cilostazol, and tirofiban on ADP-induced aggregation was tested, while aspirin was evaluated with arachidonic acid and collagen. Platelet aggregation was recorded using the MICELI or BioData PAP-8E (Bio/Data Corp.) aggregometers. RESULTS The MICELI aggregometer detected an adequate and comparable dose-dependent decrease of platelet aggregation in response to increments of drugs' concentrations, as compared to LTA (the inter-device R2 = 0.79-0.93). Platelet aggregation in platelet-rich plasma recorded by LTA showed higher sensitivity to antiplatelet agents, but it couldn't distinguish between different drug doses as indicated by saturation of the aggregatory response. CONCLUSION Platelet aggregation in whole blood as recorded by EIA represents a better model system for evaluation of platelet reactivity as compared with platelet aggregation in platelet-rich plasma as recorded by LTA, since EIA takes into consideration the modulatory effect of other blood cells on platelet hemostatic function and pharmacodynamics of antiplatelet drugs in vivo. As such, the MICELI impedance aggregometer could be potentially employed for the point-of-care monitoring of platelet function in patients on-treatment for personalized tailoring of their antiplatelet regimen.
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Affiliation(s)
- Tatiana Mencarini
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Yana Roka-Moiia
- Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, United States of America; Department of Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ, United States of America
| | - Silvia Bozzi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Marvin J Slepian
- Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, United States of America; Department of Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ, United States of America.
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Mystakidi VC, Oikonomou E, Tousoulis D. Current Antithrombotic Therapy: Beyond Coronary Artery Disease. Curr Pharm Des 2020; 26:2683-2685. [DOI: 10.2174/138161282623200625103419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Vasiliki-Chara Mystakidi
- Department of Cardiology, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Oikonomou
- Department of Cardiology, ‘Hippokration’ General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitris Tousoulis
- Department of Cardiology, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Siontis GC, Räber L. Consistent benefits of IVUS-guidance in complex coronary lesions: It is time to change your PCI practice! Int J Cardiol 2020; 301:38-39. [PMID: 31744719 DOI: 10.1016/j.ijcard.2019.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Affiliation(s)
- George Cm Siontis
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
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Fontana P, Roffi M, Reny JL. Platelet Function Test Use for Patients with Coronary Artery Disease in the Early 2020s. J Clin Med 2020; 9:jcm9010194. [PMID: 31936845 PMCID: PMC7019825 DOI: 10.3390/jcm9010194] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
In the field of antithrombotics, precision medicine is of particular interest, as it may lower the incidence of potentially life-threatening side effects. Indeed, antiplatelet drugs such as P2Y12 inhibitors are one of the most common causes of emergency admissions for drug-related adverse events. The last ten years have seen a continuous debate on whether platelet function tests (PFTs) should be used to tailor antiplatelet drugs to cardiovascular patients. Large-scale randomized studies investigating the escalation of antiplatelet therapies according to the results of PFTs were mostly negative. Potent P2Y12 inhibitors are recommended as a first-line treatment in acute coronary syndrome patients, bringing the bleeding risk at the forefront. De-escalation from prasugrel or ticagrelor to clopidogrel is now considered, with or without the use of a PFT. This review covers recent advances in escalation and de-escalation strategies based on PFTs in various clinical settings. It also describes the main features of the most popular platelet function tests as well as the potential added value of genetic testing. Finally, we detail practical suggestions on how PFTs could be used in clinical practice.
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Affiliation(s)
- Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Division of Angiology and Haemostasis, Geneva University Hospitals, 1205 Geneva, Switzerland
- Correspondence: ; Tel.: +41-22-372-97-51; Fax: +41-22-372-98-91
| | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, 1206 Geneva, Switzerland;
- Division of General Internal Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
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Blais MC, Bianco D, Goggs R, Lynch AM, Palmer L, Ralph A, Sharp CR. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 3-Defining antithrombotic protocols. J Vet Emerg Crit Care (San Antonio) 2019; 29:60-74. [PMID: 30654416 DOI: 10.1111/vec.12795] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/10/2018] [Accepted: 12/08/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To systematically examine the evidence for use of a specific protocol (dose, frequency, route) of selected antithrombotic drugs, in comparisons to no therapy or to other antithrombotic therapies, to reduce the risk of complications or improve outcomes in dogs and cats at risk for thrombosis. DESIGN Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence (LOE) and quality (Good, Fair, or Poor), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. SETTINGS Academic and referral veterinary medical centers. RESULTS Databases searched included Medline via PubMed and CAB abstracts. Eight different antithrombotic drugs were investigated using a standardized Patient, Intervention, Comparison, Outcome (PICO) question format both for dogs and cats, including aspirin, clopidogrel, warfarin, unfractionated heparin (UFH), dalteparin, enoxaparin, fondaparinux, and rivaroxaban, generating a total of 16 worksheets. Most studies identified were experimental controlled laboratory studies in companion animals (LOE 3) with only four randomized controlled clinical trials in companion animals (LOE 1). CONCLUSIONS Overall, evidence-based recommendations concerning specific protocols could not be formulated for most antithrombotic drugs evaluated, either because of the wide range of dosage reported (eg, aspirin in dogs) or the lack of evidence in the current literature. However, clopidogrel administration in dogs and cats at risk of arterial thrombosis, notably in cats at risk of cardiogenic thromboembolism, is supported by the literature, and specific protocols were recommended. Comparably, aspirin should not be used as a sole antithrombotic in cats with cardiomyopathy. Using the available safety profile information contained in the literature, the panel reached consensus on suggested dosage schemes for most antithrombotics. Significant knowledge gaps were highlighted, which will hopefully drive novel research.
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Affiliation(s)
- Marie-Claude Blais
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, St-Hyacinthe, Quebec, Canada
| | - Domenico Bianco
- Internal Medicine Department, Metropolitan Animal Specialty Hospital, Los Angeles, CA
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Alex M Lynch
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC
| | - Lee Palmer
- Lieutenant Colonel, US Army Reserve, Veterinary Corps, Chair K9 Tactical Emergency Casualty Care Working Group, New Orleans, LA
| | | | - Claire R Sharp
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia
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14
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Ivlev DA, Shirinli SN, Guria KG, Uzlova SG, Guria GT. Control of fibrinolytic drug injection via real-time ultrasonic monitoring of blood coagulation. PLoS One 2019; 14:e0211646. [PMID: 30811424 PMCID: PMC6392241 DOI: 10.1371/journal.pone.0211646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/17/2019] [Indexed: 12/02/2022] Open
Abstract
In the present study, we investigated the capabilities of a novel ultrasonic approach for real-time control of fibrinolysis under flow conditions. Ultrasonic monitoring was performed in a specially designed experimental in vitro system. Fibrinolytic agents were automatically injected at ultrasonically determined stages of the blood clotting. The following clots dissolution in the system was investigated by means of ultrasonic monitoring. It was shown, that clots resistance to fibrinolysis significantly increases during the first 5 minutes since the formation of primary micro-clots. The efficiency of clot lysis strongly depends on the concentration of the fibrinolytic agent as well as the delay of its injection moment. The ultrasonic method was able to detect the coagulation at early stages, when timely pharmacological intervention can still prevent the formation of macroscopic clots in the experimental system. This result serves as evidence that ultrasonic methods may provide new opportunities for real-time monitoring and the early pharmacological correction of thrombotic complications in clinical practice.
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Affiliation(s)
| | | | | | | | - Georgy Th. Guria
- National Research Center for Hematology, Moscow, Russia
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia
- * E-mail:
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15
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Rodriguez-Bernal CL, Peiró S, Hurtado I, García-Sempere A, Sanfélix-Gimeno G. Primary Nonadherence to Oral Anticoagulants in Patients with Atrial Fibrillation: Real-World Data from a Population-Based Cohort. J Manag Care Spec Pharm 2018; 24:440-448. [PMID: 29694286 PMCID: PMC10398152 DOI: 10.18553/jmcp.2018.24.5.440] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Primary nonadherence (not filling a first prescription) is an important yet unstudied aspect of adherence to oral anticoagulant (OAC) therapy. OBJECTIVE To estimate the rates of primary nonadherence to OACs and determine associated factors in real-world practice. METHODS This population-based retrospective cohort study set in the Valencia region of Spain (about 5 million inhabitants) included all patients with atrial fibrillation who were newly prescribed OACs during 2011-2014 (N = 18,715). Primary nonadherence was obtained by linking electronic prescription and dispensing data and assessed by type of OAC-vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs). Covariates were obtained from diverse databases, including electronic medical records. Multivariate logistic regression models were used to assess characteristics associated with primary nonadherence, adjusting for a propensity score to minimize confounding by indication. RESULTS Primary nonadherence to OACs was 5.62% (VKA 4.29% vs. NOAC 10.81%; P < 0.001), with varying rates among specific drugs (acenocoumarol 4.2%, warfarin 10.9%, apixaban 5.0%, dabigatran 7.9%, and rivaroxaban 15.5%). After adjusting for potential confounders, the likelihood of not filling the first prescription was higher for NOAC patients than for VKA patients (OR = 2.76, 95% CI = 2.41-3.15). High coinsurance in the older groups (OR = 2.63, 95% CI = 1.47-4.69 for patients aged 66-75 years and OR = 3.02, 95% CI = 1.58-5.76 for patients aged > 75 years); being a non-Spanish European (OR = 1.49, 95% CI = 1.12-1.99); and having dementia (OR = 1.72, 95% CI = 1.37-2.16) were positively associated with primary nonadherence. Electronic transmission of prescriptions (OR = 0.85, 95% CI = 0.74-0.96); liver disease (OR = 0.73, 95% CI = 0.54-0.99); and polypharmacy (OR = 0.59, 95% CI = 0.50-0.70) were inversely associated with primary nonadherence. CONCLUSIONS Overall, primary nonadherence to OACs was relatively low (5%). However, important differences were found between VKAs and NOACs. After adjustment, patients prescribed NOACs nearly tripled the likelihood of nonadherence compared with patients prescribed VKAs, which could negatively affect their effectiveness in clinical practice. Identified correlates were similar to those shown in the limited evidence for other medications. DISCLOSURES This work was partially supported by the 2013 Collaboration Agreement between the Fundación para el Fomento de la Investigación Sanitaria y Biomédica (FISABIO) from the Valencia Ministry of Health and Boehringer Ingelheim, a nonconditioned program to conduct independent research in chronic health care, pharmacoepidemiology, and medical practice variation. Rodriguez-Bernal was funded by the Instituto de Salud Carlos III, Spanish Ministry of Health, and cofinanced by the European Regional Development Fund (grant number RD12/0001/0005). The views presented here are those of the authors and not necessarily those of the FISABIO Foundation, the Valencia Ministry of Health, or the study sponsors. The funding sources had no access to study data and did not participate in any way in the design or conduct of the study, data analysis, decisions regarding the dissemination of findings, the development of the manuscript, or its publication. Peiró has received fees for participation in scientific meetings and courses sponsored by Novartis and Ferrer International. In 2014, Sanfélix-Gimeno participated in an advisory meeting of Boehringer Ingelheim. García-Sempere is a former employee of Boehringer Ingelheim. Rodriguez-Bernal and Hurtado have no relationships relevant to the contents of this article to disclose. This work was previously submitted as an abstract (podium presentation) at the 31st International Society of Pharmacoepidemiology (ISPE) Annual Conference; August 22-26, 2015; Boston, Massachusetts.
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Affiliation(s)
- Clara L Rodriguez-Bernal
- 1 Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO) and Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Salvador Peiró
- 1 Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO) and Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Isabel Hurtado
- 1 Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO) and Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Aníbal García-Sempere
- 2 Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- 1 Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO) and Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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16
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Yao Y, Zhang B, Zhu H, Li H, Han Y, Chen K, Wang Z, Zeng J, Liu Y, Wang X, Li Y, He D, Lin P, Zhou X, Park KH, Bian Z, Chen Z, Gong N, Tan T, Zhou J, Zhang M, Ma J, Zeng C. MG53 permeates through blood-brain barrier to protect ischemic brain injury. Oncotarget 2017; 7:22474-85. [PMID: 26967557 PMCID: PMC5008374 DOI: 10.18632/oncotarget.7965] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 02/11/2016] [Indexed: 11/25/2022] Open
Abstract
Ischemic injury to neurons represents the underlying cause of stroke to the brain. Our previous studies identified MG53 as an essential component of the cell membrane repair machinery. Here we show that the recombinant human (rh)MG53 protein facilitates repair of ischemia-reperfusion (IR) injury to the brain. MG53 rapidly moves to acute injury sites on neuronal cells to form a membrane repair patch. IR-induced brain injury increases permeability of the blood-brain-barrier, providing access of MG53 from blood circulation to target the injured brain tissues. Exogenous rhMG53 protein can protect cultured neurons against hypoxia/reoxygenation-induced damages. Transgenic mice with increased levels of MG53 in the bloodstream are resistant to IR-induced brain injury. Intravenous administration of rhMG53, either prior to or after ischemia, can effectively alleviate brain injuries in rats. rhMG53-mediated neuroprotection involves suppression of apoptotic neuronal cell death, as well as activation of the pro-survival RISK signaling pathway. Our data indicate a physiological function for MG53 in the brain and suggest that targeting membrane repair or RISK signaling may be an effective means to treat ischemic brain injury.
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Affiliation(s)
- Yonggang Yao
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Bo Zhang
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA.,Institute of Organ Transplantation, Huazhong University of Science and Technology - Tongji Medical College, Wuhan, P.R. China
| | - Hua Zhu
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Haichang Li
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Yu Han
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Ken Chen
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Zhen Wang
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Jing Zeng
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Yukai Liu
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Xinquan Wang
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Yu Li
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Duofen He
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
| | - Peihui Lin
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Xinyu Zhou
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Ki Ho Park
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Zehua Bian
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Zhishui Chen
- Institute of Organ Transplantation, Huazhong University of Science and Technology - Tongji Medical College, Wuhan, P.R. China
| | - Nianqiao Gong
- Institute of Organ Transplantation, Huazhong University of Science and Technology - Tongji Medical College, Wuhan, P.R. China
| | - Tao Tan
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Jingsong Zhou
- Department of Physiology, Kansas City University of Medicine & Bioscience, Kansas City, MO, USA
| | - Meng Zhang
- Department of Neurology, Daping Hospital, The Third Military Medical University, Chongqing, P.R. China
| | - Jianjie Ma
- Department of Surgery, Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Chunyu Zeng
- Department of Cardiology, Daping Hospital, The Third Military Medical University, Chongqing Institute of Cardiology, Chongqing, P.R. China
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17
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18
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García-Sempere A, Bejarano-Quisoboni D, Librero J, Rodríguez-Bernal CL, Peiró S, Sanfélix-Gimeno G. A Multilevel Analysis of Real-World Variations in Oral Anticoagulation Initiation for Atrial Fibrillation in Valencia, a European Region. Front Pharmacol 2017; 8:576. [PMID: 28883793 PMCID: PMC5573806 DOI: 10.3389/fphar.2017.00576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022] Open
Abstract
Introduction: Beyond clinical trials, clinical practice guidelines, and administrative regulation, treatment decision-making can be influenced by individual and contextual factors. Our goal was to describe variations in the patterns of initiation of anticoagulation therapy in patients with atrial fibrillation by Health Areas (HA) in the region of Valencia in Spain and to quantify the influence of the HAs on variations in treatment choice. Methods: We conducted a population-based retrospective cohort study of all atrial fibrillation patients who started treatment with oral anticoagulants between November 2011 and February 2014 in each of the region's 24 HAs. We described patient and utilization characteristics per HA and initiation patterns over time, and we identified contextual and individual factors associated with differences in initiation patterns. Results: 21,879 patients initiated treatment with an oral anticoagulant in the 24 HAs. Initiation with direct oral anticoagulants (DOAC) in the first year was 14.6%. In November 2013 the ratio was 25.4%, with HA ratios ranging from 3.8 to 57.1%. DOAC-initiating patients had less comorbidity but were more likely to present episodes of previous ischemic stroke, hemorrhagic stroke, or TIA when compared with patients initiating with VKA treatment. Variability among HAs was statistically significant, with the majority of HAs ranking above or below the regional initiation average (ICC ≈ 8%). Conclusion: There was high variability in the percentage of DOAC initiation and in the choice of DOAC among HAs. Interventions aimed to improve DOAC initiation decision-making and to reduce variations should take into account the Health Area component.
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Affiliation(s)
- Aníbal García-Sempere
- Center for Public Health Research (CSISP-FISABIO)Valencia, Spain.,Spanish Network of Chronic Care and Health Services Research (REDISSEC)Valencia, Spain
| | | | - Julián Librero
- Spanish Network of Chronic Care and Health Services Research (REDISSEC)Valencia, Spain.,Navarrabiomed Biomedical Research CentrePamplona, Spain
| | - Clara L Rodríguez-Bernal
- Center for Public Health Research (CSISP-FISABIO)Valencia, Spain.,Spanish Network of Chronic Care and Health Services Research (REDISSEC)Valencia, Spain
| | - Salvador Peiró
- Center for Public Health Research (CSISP-FISABIO)Valencia, Spain.,Spanish Network of Chronic Care and Health Services Research (REDISSEC)Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Center for Public Health Research (CSISP-FISABIO)Valencia, Spain.,Spanish Network of Chronic Care and Health Services Research (REDISSEC)Valencia, Spain
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19
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Lee IJ, Yang YC, Hsu JW, Chang WT, Chuang YJ, Liau I. Zebrafish model of photochemical thrombosis for translational research and thrombolytic screening in vivo. JOURNAL OF BIOPHOTONICS 2017; 10:494-502. [PMID: 27174426 DOI: 10.1002/jbio.201500287] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 04/22/2016] [Accepted: 04/22/2016] [Indexed: 06/05/2023]
Abstract
Acute thromboembolic diseases remain the major global cause of death or disability. Although an array of thrombolytic and antithrombotic drugs has been approved to treat or prevent thromboembolic diseases, many more drugs that target specific clotting mechanisms are under development. Here a novel zebrafish model of photochemical thrombosis is reported and its prospective application for the screening and preclinical testing of thrombolytic agents in vivo is demonstrated. Through photochemical excitation, a thrombus was induced to form at a selected section of the dorsal aorta of larval zebrafish, which had been injected with photosensitizers. Such photochemical thrombosis can be consistently controlled to occlude partially or completely the targeted blood vessel. Detailed mechanistic tests indicate that the zebrafish model of photochemical thrombosis exhibits essential features of classical coagulation and a thrombolytic pathway. For demonstration, tissue plasminogen activator (tPA), a clinically feasible thrombolytic agent, was shown to effectively dissolve photochemically induced blood clots. In light of the numerous unique advantages of zebrafish as a model organism, our approach is expected to benefit not only the development of novel thrombolytic and antithrombotic strategies but also the fundamental or translational research targeting hereditary thrombotic or coagulation disorders.
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Affiliation(s)
- I-Ju Lee
- Department of Applied Chemistry and Institute of Molecular Science, National Chiao Tung University, Hsinchu, 300, Taiwan
| | - Yi-Cyun Yang
- Department of Applied Chemistry and Institute of Molecular Science, National Chiao Tung University, Hsinchu, 300, Taiwan
| | - Jia-Wen Hsu
- Department of Applied Chemistry and Institute of Molecular Science, National Chiao Tung University, Hsinchu, 300, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine and Cardiovascular Center, National Taiwan University Hospital and College of Medicine, Taipei, 100, Taiwan
| | - Yung-Jen Chuang
- Department of Medical Science and Institute of Bioinformatics and Structural Biology, National Tsing Hua University, Hsinchu, 300, Taiwan
| | - Ian Liau
- Department of Applied Chemistry and Institute of Molecular Science, National Chiao Tung University, Hsinchu, 300, Taiwan
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20
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Rodríguez-Bernal CL, Hurtado I, García-Sempere A, Peiró S, Sanfélix-Gimeno G. Oral Anticoagulants Initiation in Patients with Atrial Fibrillation: Real-World Data from a Population-Based Cohort. Front Pharmacol 2017; 8:63. [PMID: 28261098 PMCID: PMC5314137 DOI: 10.3389/fphar.2017.00063] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/30/2017] [Indexed: 12/15/2022] Open
Abstract
Objective: Little is known about initial prescription of currently used oral anticoagulants (OAC), and correlated characteristics in real-world practice. We aimed to assess patterns of initiation of Vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) in naive patients with non-valvular atrial fibrillation and the factors associated with starting treatment with NOAC. Methods: Population-based retrospective cohort study of all patients with NVAF who had a first prescription of OAC from November 2011 to February 2014 in the Valencia region, Spain (n = 21,881). Temporal trends of OAC initiation are described for the whole population and by type of OAC and therapeutic agent. Factors associated with starting treatment with NOAC (vs. VKA) were identified using logistic multivariate regression models. Results: Among the patients initiating OAC, 25% started with NOAC 2 years after market release. Regarding temporal trends, prescription of NOAC doubled during the study period. VKA prescription also increased (by around 13%), resulting in a 30% rise in total treatment initiation with OAC during 2011-2014. NOAC initiation (vs. VKA) was associated with a lower baseline risk of thromboembolism and higher income. Conclusions: In this Spanish population-based cohort, initiation of OAC therapy saw a rapid increase, mainly but not exclusively, due to a two-fold rise in the use of NOAC. Initiation with NOAC was associated with a lower baseline risk of thromboembolism and higher income, which opposes the indications of NOAC use and reflects disparities in care. Inadequate prescription patterns might threaten the effectiveness and safety of these therapies, thus monitoring OAC prescription is necessary and should be setting-specific.
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Affiliation(s)
- Clara L Rodríguez-Bernal
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain; Red de Investigación en Servicios de Salud en Enfermedades CrónicasValencia, Spain
| | - Isabel Hurtado
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain; Red de Investigación en Servicios de Salud en Enfermedades CrónicasValencia, Spain
| | - Aníbal García-Sempere
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain; Red de Investigación en Servicios de Salud en Enfermedades CrónicasValencia, Spain
| | - Salvador Peiró
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain; Red de Investigación en Servicios de Salud en Enfermedades CrónicasValencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain; Red de Investigación en Servicios de Salud en Enfermedades CrónicasValencia, Spain
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21
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Lee J, Lee W, Kim MA, Hwang JS, Na M, Bae JS. Inhibition of platelet aggregation and thrombosis by indole alkaloids isolated from the edible insect Protaetia brevitarsis seulensis (Kolbe). J Cell Mol Med 2016; 21:1217-1227. [PMID: 27997749 PMCID: PMC5431138 DOI: 10.1111/jcmm.13055] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/10/2016] [Indexed: 12/13/2022] Open
Abstract
Protaetia brevitarsis seulensis (Kolbe) has been temporarily registered as a food material by the Ministry of Food and Drug Safety of Korea (MFDS). The current study aimed to discover small antithrombotic molecules from this edible insect. Five indole alkaloids, 5‐hydroxyindolin‐2‐one (1), (1R,3S)‐1‐methyl‐1,2,3,4‐tetrahydro‐β‐carboline‐3‐carboxylic acid (2), (1S,3S)‐1‐methyl‐1,2,3,4‐tetrahydro‐β‐carboline‐3‐carboxylic acid (3), (3S)‐1,2,3,4‐tetrahydro‐β‐carboline‐3‐carboxylic acid (4) and L‐tryptophan (5), were isolated from the insect. Among them, compounds 1 and 2 prolonged aPTT and PT and impaired thrombin and FXa generation on HUVEC surface. Moreover, these compounds inhibited platelet aggregation. Antithrombotic effects of compounds 1 and 2 were further confirmed in pre‐clinical models of pulmonary embolism and arterial thrombosis. Collectively, these results demonstrated that compounds 1 and 2 could be effective antithrombotic agents and serve as new scaffolds for the development of antithrombotic drug.
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Affiliation(s)
- JungIn Lee
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Wonhwa Lee
- College of Pharmacy, CMRI, Research Institute of Pharmaceutical Sciences, BK21 Plus KNU Multi-Omics based Creative Drug Research Team, Kyungpook National University, Daegu, Republic of Korea
| | - Mi-Ae Kim
- College of Pharmacy, CMRI, Research Institute of Pharmaceutical Sciences, BK21 Plus KNU Multi-Omics based Creative Drug Research Team, Kyungpook National University, Daegu, Republic of Korea.,Department of Agricultural Biology, The National Academy of Agricultural Science, RDA, Wanju-gun, Republic of Korea
| | - Jae Sam Hwang
- Department of Agricultural Biology, The National Academy of Agricultural Science, RDA, Wanju-gun, Republic of Korea
| | - MinKyun Na
- College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea
| | - Jong-Sup Bae
- College of Pharmacy, CMRI, Research Institute of Pharmaceutical Sciences, BK21 Plus KNU Multi-Omics based Creative Drug Research Team, Kyungpook National University, Daegu, Republic of Korea
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22
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Lordkipanidzé M, So D, Tanguay JF. Platelet function testing as a biomarker for efficacy of antiplatelet drugs. Biomark Med 2016; 10:903-18. [DOI: 10.2217/bmm-2016-0070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the overwhelming evidence in support of the efficacy of dual antiplatelet therapy with aspirin and clopidogrel, it is also obvious that not all patients benefit from these drugs to the same extent. This interindividual variability in platelet responses may underlie clinical differences in drug efficacy, with potential for optimization of antiplatelet therapy to prevent ischemic events without excessively increasing bleeding risk. This review presents the current evidence regarding platelet function testing for monitoring of antiplatelet therapy, with emphasis on the prognostic value of platelet function testing to predict ischemic and bleeding events. The potential of platelet function testing to provide personalized antiplatelet therapy is also discussed, with an outlook toward the future of platelet function testing in high-risk individuals.
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Affiliation(s)
- Marie Lordkipanidzé
- Faculté de Pharmacie, Université de Montréal, C.P. 6128, Succ. Centre-ville, Montréal, QC, H3C 3J7, Canada
- Research Center, Montreal Heart Institute, 5000 rue Bélanger, Montréal, QC, H1T 1C8, Canada
| | - Derek So
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, K1Y 4W7, Canada
| | - Jean-François Tanguay
- Faculté de Médecine, Université de Montréal, C.P. 6128, succ. Centre-ville, Montréal, QC, H3C 3J7, Canada
- Department of Medicine, Montreal Heart Institute, 5000 rue Bélanger, Montréal, QC, H1T 1C8, Canada
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23
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Bhatt DL, Hunt RH. Concurrent Lower Gastrointestinal Bleeding Risk and Myocardial Ischemic Risk: Resume Aspirin or Not? Gastroenterology 2016; 151:222-5. [PMID: 27374367 DOI: 10.1053/j.gastro.2016.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts.
| | - Richard H Hunt
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University Health Science Centre, Hamilton, Ontario, Canada
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Affiliation(s)
- Deepak L Bhatt
- From Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Harvard T.H. Chan School of Public Health (C.M.), Boston, and Cytel, Cambridge (C.M.) - all in Massachusetts
| | - Cyrus Mehta
- From Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.) and Harvard T.H. Chan School of Public Health (C.M.), Boston, and Cytel, Cambridge (C.M.) - all in Massachusetts
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Abstract
Certain antithrombotic drugs exhibit high patient-to-patient variability that significantly impacts the safety and efficacy of therapy. Pharmacogenetics offers the possibility of tailoring drug treatment to patients based on individual genotypes, and this type of testing has been recommended for 2 oral antithrombotic agents, warfarin and clopidogrel, to influence use and guide dosing. Limited studies have identified polymorphisms that affect the metabolism and activity of newer oral antithrombotic drugs, without clear evidence of the clinical relevance of such polymorphisms. This article provides an overview of the current status of pharmacogenetics in oral antithrombotic therapy.
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Alexander Duncan
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Charles E Hill
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Emory University School of Medicine, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA
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Sanfélix-Gimeno G, Rodríguez-Bernal CL, Hurtado I, Baixáuli-Pérez C, Librero J, Peiró S. Adherence to oral anticoagulants in patients with atrial fibrillation-a population-based retrospective cohort study linking health information systems in the Valencia region, Spain: a study protocol. BMJ Open 2015; 5:e007613. [PMID: 26482766 PMCID: PMC4611755 DOI: 10.1136/bmjopen-2015-007613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adherence to oral anticoagulation (OAC) treatment, vitamin K antagonists or new oral anticoagulants, is an essential element for effectiveness. Information on adherence to OAC in atrial fibrillation (AF) and the impact of adherence on clinical outcomes using real-world data barely exists. We aim to describe the patterns of adherence to OAC over time in patients with AF, estimate the associated factors and their impact on clinical events, and assess the same issues with conventional measures of primary and secondary adherence-proportion of days covered (PDC) and persistence-in routine clinical practice. METHODS AND ANALYSIS This is a population-based retrospective cohort study including all patients with AF treated with OAC from 2010 to date in Valencia, Spain; data will be obtained from diverse electronic records of the Valencia Health Agency. PRIMARY OUTCOME MEASURE adherence trajectories. SECONDARY OUTCOMES (1) primary non-adherence; (2) secondary adherence: (a) PDC, (b) persistence. Clinical outcomes: hospitalisation for haemorrhagic or thromboembolic events and death during follow-up. ANALYSIS (1) description of baseline characteristics, adherence patterns (trajectory models or latent class growth analysis models) and conventional adherence measures; (2) logistic or Cox multivariate regression models, to assess the associations between adherence measures and the covariates, and logistic multinomial regression models, to identify characteristics associated with each trajectory; (3) Cox proportional hazard models, to assess the relationship between adherence and clinical outcomes, with propensity score adjustment applied to further control for potential confounders; (4) to estimate the importance of different healthcare levels in the variations of adherence, logistic or Cox multilevel regression models. ETHICS AND DISSEMINATION This study has been approved by the corresponding Clinical Research Ethics Committee. We plan to disseminate the project's findings through peer-reviewed publications and presentations at relevant health conferences. Policy reports will also be prepared in order to promote the translation of our findings into policy and clinical practice.
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Affiliation(s)
- G Sanfélix-Gimeno
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - C L Rodríguez-Bernal
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - I Hurtado
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - C Baixáuli-Pérez
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - J Librero
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - S Peiró
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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Bhatt DL, Hulot JS, Moliterno DJ, Harrington RA. Antiplatelet and Anticoagulation Therapy for Acute Coronary Syndromes. Circ Res 2014; 114:1929-43. [DOI: 10.1161/circresaha.114.302737] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Deepak L. Bhatt
- From the Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (D.L.B.); Icahn School of Medicine at Mount Sinai, Cardiovascular Research Institute, New York, NY (J.-S.H.); Department of Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); and Stanford University, CA (R.A.H.)
| | - Jean-Sébastien Hulot
- From the Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (D.L.B.); Icahn School of Medicine at Mount Sinai, Cardiovascular Research Institute, New York, NY (J.-S.H.); Department of Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); and Stanford University, CA (R.A.H.)
| | - David J. Moliterno
- From the Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (D.L.B.); Icahn School of Medicine at Mount Sinai, Cardiovascular Research Institute, New York, NY (J.-S.H.); Department of Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); and Stanford University, CA (R.A.H.)
| | - Robert A. Harrington
- From the Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (D.L.B.); Icahn School of Medicine at Mount Sinai, Cardiovascular Research Institute, New York, NY (J.-S.H.); Department of Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); and Stanford University, CA (R.A.H.)
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Platelet function testing in contemporary clinical and interventional practice. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:300. [PMID: 24652579 DOI: 10.1007/s11936-014-0300-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Dual antiplatelet therapy with a combination of aspirin and an inhibitor of the ADP P2Y12 receptor is the recommended treatment for patients with acute coronary syndrome or who are undergoing percutaneous coronary intervention (PCI). However, patients may continue to have ischemic recurrences, including stent thrombosis, which have been linked with the well-known variability in individual response to antiplatelet therapy, and clopidogrel in particular. There are currently several assays available to measure platelet reactivity, and platelet function testing has been shown to be a valuable tool to assess the pharmacodynamic efficacy of antiplatelet drugs. Moreover, platelet reactivity has important prognostic implications, as several studies have shown an association with thrombotic and bleeding events in patients with high and low platelet reactivity, respectively. Consequently, over the past years there has been a plethora of studies investigating the optimal range of platelet reactivity associated with the highest protection against ischemic complications and the lowest risk of bleeding. Given the correlation between on-treatment platelet reactivity and outcomes, the use of platelet function testing has also been advocated to create personalized antiplatelet therapy. Several studies have been conducted in this field, but major clinical trials have failed to demonstrate a benefit of such a strategy in improving clinical outcomes. Indeed, inherent limitations of these trials may have contributed to their failure. The present manuscript provides an overview on the role of platelet function testing in contemporary clinical and interventional practice.
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Würtz M, Lordkipanidzé M, Grove EL. Pharmacogenomics in cardiovascular disease: focus on aspirin and ADP receptor antagonists. J Thromb Haemost 2013; 11:1627-39. [PMID: 23809178 DOI: 10.1111/jth.12318] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Indexed: 11/27/2022]
Abstract
Antiplatelet agents like aspirin and adenosine diphosphate receptor antagonists are effective in reducing recurrent ischemic events. Considerable inter-individual variability in the platelet inhibition obtained with these drugs has initiated a search for explanatory mechanisms and ways to improve treatment. In recent years, numerous genetic polymorphisms have been linked with reduced platelet inhibition and lack of clinical efficacy of antiplatelet drugs, particularly clopidogrel and aspirin. Consequently, attempts to adjust antiplatelet treatment according to genotype have been made, but the clinical benefit has been modest in studies performed so far. The progress in genome science over the last decade and the declining cost of sequencing technologies hold the promise of enabling genetically tailored antiplatelet therapy. However, more evidence is needed to clarify which polymorphisms may serve as targets to improve treatment. The present review outlines the panel of polymorphisms affecting the benefit of aspirin and adenosine diphosphate receptor antagonists, including novel and ongoing studies evaluating whether genotyping may be beneficial in tailoring antiplatelet therapy.
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Affiliation(s)
- M Würtz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Watson SP, Lowe GC, Lordkipanidzé M, Morgan NV. Genotyping and phenotyping of platelet function disorders. J Thromb Haemost 2013; 11 Suppl 1:351-63. [PMID: 23516995 DOI: 10.1111/jth.12199] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The majority of patients with platelet function disorders (PFDs) have normal platelet counts and mild day-to-day bleeding symptoms, but are at risk of major hemorrhage at times of trauma, surgery, or childbirth. This group is challenging to investigate, because the assays are often time-intensive and labour-intensive, and interpretation is difficult, especially in patients with mild disorders. In addition, interuser variability in performance of the assays, including the currently accepted gold standard, light transmission aggregometry, makes the results difficult to compare between laboratories. Furthermore, a similar pattern of mucocutaneous bleeding is seen in disorders in other components of the hemostatic pathway, including type 1 von Willebrand disease (VWD). We have undertaken an extensive investigation of patients with clinically diagnosed excessive bleeding, using a genotyping and platelet phenotyping approach based on lumi-aggregometry, and other specialist tests of platelet function, in combination with Sanger and next-generation sequencing (NGS). We found a functional defect in ~ 60% of patients, the majority being associated with feedback pathways of platelet activation. Function-disrupting mutations were identified in known and novel genes, and coinheritance with other genetic disorders of hemostasis, including type 1 VWD, was shown. A significant number of mutations are heterozygous and unlikely to cause extensive bleeding in isolation, consistent with incomplete penetrance of inheritance of bleeding disorders and a multifactorial etiology for excessive bleeding in many patients. Mucocutaneous bleeding is a complex trait, and this has important implications for NGS in the assessment of a PFD.
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Affiliation(s)
- S P Watson
- Centre for Cardiovascular Sciences, Institute of Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Raichand S, Moore D, Riley RD, Lordkipanidzé M, Dretzke J, O'Donnell J, Jowett S, Bayliss S, Fitzmaurice DA. Protocol for a systematic review of the diagnostic and prognostic utility of tests currently available for the detection of aspirin resistance in patients with established cardiovascular or cerebrovascular disease. Syst Rev 2013; 2:16. [PMID: 23442317 PMCID: PMC3600664 DOI: 10.1186/2046-4053-2-16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 02/18/2013] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The benefits of aspirin as an anti-platelet agent are well established; however, there has been much debate about the lack of uniformity in the efficacy of aspirin to inhibit platelet function. In some patients, aspirin fails to inhibit platelets even where compliance has been verified, a phenomenon which has been termed "aspirin resistance". These patients may in turn be at a higher risk of future vascular events. The proportion of "resistant" patients identified depends on the type of platelet function test. Therefore, the aim of this systematic review is to determine which, if any, platelet function test has utility in terms of identifying patients with a high risk of vascular events. The review has been registered with PROSPERO (CRD42012002151). METHODS Relevant studies will be sought from bibliographic databases. Trials registers will be searched for ongoing studies. Reference lists will be checked and subject experts contacted. There will be no date or language restrictions. Standard reviewing methodology to minimise bias will be employed. Any prospective studies in patients on aspirin therapy and assessing platelet function in relation to relevant clinical outcomes will be included, as will studies reporting prognostic models. Risk of bias assessment will be based on the Quality Assessment of Diagnostic Accuracy Studies guidelines, and suitable criteria for assessing quality of prognostic studies. Data on test accuracy measures, relative risks, odds or hazard ratios will be extracted and meta-analysed, where possible, using a random-effects model to account for between-study heterogeneity. Where appropriate, the causes of heterogeneity will be explored through meta-regression and sub-group or sensitivity analyses. If platelet function testing is demonstrated to have diagnostic/predictive utility in a specific population, the potential for a cost-effectiveness analysis will be considered and, if possible, an economic model constructed. This will be supported by a systematic review of existing economic evaluation studies. DISCUSSION The results of the review could indicate if platelet function test(s) could lead to a reliable prediction of the risk of clinically important events in a defined population, and thus support investigations into adjustments to therapy in order to compensate for a predicted poor response to standard aspirin.
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Affiliation(s)
- Smriti Raichand
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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