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Zuccarelli V, Andreaggi S, Walsh JL, Kotronias RA, Chu M, Vibhishanan J, Banning AP, De Maria GL. Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention? J Clin Med 2024; 13:2923. [PMID: 38792463 PMCID: PMC11122374 DOI: 10.3390/jcm13102923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.
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Affiliation(s)
- Vittorio Zuccarelli
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
| | - Stefano Andreaggi
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiology, Department of Medicine, University of Verona, 37129 Verona, Italy
| | - Jason L. Walsh
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Miao Chu
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Jonathan Vibhishanan
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK; (V.Z.); (S.A.); (J.L.W.); (R.A.K.); (M.C.); (J.V.); (A.P.B.)
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
- National Institute for Health Research (NIHR), Oxford Biomedical Research Centre, Oxford OX3 9DU, UK
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Wilschut JM, Vogel RF, Elscot JJ, Delewi R, Lemmert ME, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Smits PC, Vlachojannis GJ, Van Mieghem NM, Diletti R. Prehospital crushed versus integral prasugrel loading dose in STEMI patients with a large myocardial area. EUROINTERVENTION 2024; 20:e436-e444. [PMID: 38562070 PMCID: PMC10979386 DOI: 10.4244/eij-d-23-00618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The effect of administering a crushed prasugrel loading dose is uncertain in patients presenting with a large myocardial infarction and ST-segment elevation myocardial infarction (STEMI). AIMS The aim of this study was to investigate if patients with a large myocardial infarction may benefit from prehospital administration of a crushed prasugrel loading dose. METHODS Patients from the CompareCrush trial with an available ambulance electrocardiography (ECG) were included in the study. An independent core laboratory confirmed a prehospital large myocardial area. We compared pre- and postprocedural angiographic markers, including Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the infarct-related artery, high thrombus burden, and myocardial blush grade 3, in STEMI patients with and without a prehospital large myocardial area. RESULTS Ambulance ECG was available for 532 patients, of whom 331 patients were identified with a prehospital large myocardial area at risk. Crushed prasugrel significantly improved postprocedural TIMI 3 flow rates in STEMI patients with a prehospital large myocardial area at risk (92% vs 79%, odds ratio [OR] 3.00, 95% confidence interval [CI]: 1.50-6.00) but not in STEMI patients without a prehospital large myocardial area at risk (91% vs 95%, OR 0.47, 95% CI: 0.14-1.57; pinteraction=0.009). CONCLUSIONS Administration of crushed prasugrel may improve postprocedural TIMI 3 flow in STEMI patients with signs of a large myocardial area at risk on the ambulance ECG. The practice of crushing tablets of prasugrel loading dose might, therefore, represent a safe, fast and cost-effective strategy to improve myocardial reperfusion in this high-risk STEMI subgroup undergoing primary percutaneous coronary intervention.
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Affiliation(s)
| | - Rosanne F Vogel
- University Medical Center Utrecht, Utrecht, the Netherlands
- Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Jacob J Elscot
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ronak Delewi
- Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Miguel E Lemmert
- Erasmus University Medical Center, Rotterdam, the Netherlands
- Isala Hospital, Zwolle, the Netherlands
| | | | - Rutger-Jan Nuis
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- Sorbonne University, ACTION group, Groupe Hospitalier Pitié Salpêtrière (AP-HP), Paris, France
| | | | | | | | | | | | - Roberto Diletti
- Erasmus University Medical Center, Rotterdam, the Netherlands
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01003-3. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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Coughlan J, Durand R. Cangrelor to optimise platelet inhibition in STEMI patients pre-treated with ticagrelor: A Sisyphean task? IJC HEART & VASCULATURE 2024; 50:101355. [PMID: 38419607 PMCID: PMC10899725 DOI: 10.1016/j.ijcha.2024.101355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- J.J. Coughlan
- Dept. of Cardiology & Cardiovascular Research Institute, Mater Private Network, Eccles Street 73, Dublin 7 D07 WKW8, Ireland
| | - Rory Durand
- Dept. of Cardiology & Cardiovascular Research Institute, Mater Private Network, Eccles Street 73, Dublin 7 D07 WKW8, Ireland
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Stouffer GA, Friede KA, Rossi JS. Pretreating With P2Y 12 Inhibitors in STEMI: Does It Make Any Difference? JACC Cardiovasc Interv 2024; 17:29-31. [PMID: 38199750 DOI: 10.1016/j.jcin.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024]
Affiliation(s)
- George A Stouffer
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA; McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Kevin A Friede
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA; McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joseph S Rossi
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA
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Roule V, Beygui F, Cayla G, Rangé G, Motovska Z, Delarche N, Jourda F, Goube P, Guedeney P, Zeitouni M, El Kasty M, Laredo M, Dumaine R, Ducrocq G, Derimay F, Van Belle E, Manigold T, Cador R, Combaret N, Vicaut E, Montalescot G, Silvain J. P2Y 12 Inhibitor Loading Time Before Elective PCI and the Prevention of Myocardial Necrosis. Can J Cardiol 2024; 40:31-39. [PMID: 37660934 DOI: 10.1016/j.cjca.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND There are dated and conflicting data about the optimal timing of initiation of P2Y12 inhibitors in elective percutaneous coronary intervention (PCI). Peri-PCI myocardial necrosis is associated with poor outcomes. We aimed to assess the impact of the P2Y12 inhibitor loading time on periprocedural myocardial necrosis in the population of the randomized Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting (ALPHEUS) trial, which compared ticagrelor with clopidogrel in high-risk patients who received elective PCI. METHODS The ALPHEUS trial divided 1809 patients into quartiles of loading time. The ALPHEUS primary outcome was used (type 4 [a or b] myocardial infarction or major myocardial injury) as well as the main secondary outcome (type 4 [a or b] myocardial infarction or any type of myocardial injury). RESULTS Patients in the first quartile group (Q1) presented higher rates of the primary outcome (P = 0.01). When compared with Q1, incidences of the primary outcome decreased in patients with longer loading times (adjusted odds ratio [adjOR], 0.70 [0.52.-0.95]; P = 0.02 for Q2; adjOR 0.65 [0.48-0.88]; P < 0.01 for Q3; adjOR 0.66 [0.49-0.89]; P < 0.01 for Q4). Concordant results were found for the main secondary outcome. There was no interaction with the study drug allocated by randomization (clopidogrel or ticagrelor). Bleeding complications (any bleeding ranging between 4.9% and 7.3% and only 1 major bleeding at 48 hours) and clinical ischemic events were rare and did not differ among groups. CONCLUSIONS In elective PCI, administration of the oral P2Y12 inhibitor at the time of PCI could be associated with more frequent periprocedural myocardial necrosis than an earlier administration. The long-term clinical consequences remain unknown.
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Affiliation(s)
- Vincent Roule
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France; Département de Cardiologie, CHU de Caen, Caen, France
| | - Farzin Beygui
- Département de Cardiologie, CHU de Caen, Caen, France
| | - Guillaume Cayla
- Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION Study Group, Nîmes, France
| | - Grégoire Rangé
- Département de Cardiologie, CH de Chartres, Chartres, France
| | - Zuzana Motovska
- Cardiocentre, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | | | | | - Pascal Goube
- Service de Cardiologie, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
| | - Paul Guedeney
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Michel Zeitouni
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Mohamad El Kasty
- Department of Cardiology, Grand Hôpital de l'Est Francilien, Jossigny, France
| | - Mikael Laredo
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Raphaëlle Dumaine
- Les Grands Prés Cardiac Rehabilitation Centre, Villeneuve St Denis, France
| | - Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - François Derimay
- Service de Cardiologie Interventionnelle, Hospices Civils de Lyon and CARMEN INSERM 1060, Lyon, France
| | - Eric Van Belle
- CHU Lille, Institut Cœur Poumon, Cardiology, and Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, INSERM U1011, Institut Pasteur de Lille, EGID, Université de Lille, Lille, France
| | | | - Romain Cador
- Department of Cardiology Saint Joseph Hospital, Paris, France
| | - Nicolas Combaret
- Department of Cardiology, Clermont-Ferrand University Hospital, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Eric Vicaut
- Unité de Recherche Clinique, ACTION Study Group, Hôpital Fernand Widal (AP-HP), Paris, France and SAMM (Statistique, Analyse et Modélisation Multidisciplinaire) EA 4543, Université Paris 1 Panthéon, Sorbonne, France
| | - Gilles Montalescot
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France. http://www.action-cœur.org
| | - Johanne Silvain
- ACTION Study Group, Sorbonne Université, INSERM UMRS1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC, Vlachojannis GJ. Direct Stenting versus Conventional Stenting in Patients with ST-Segment Elevation Myocardial Infarction-A COMPARE CRUSH Sub-Study. J Clin Med 2023; 12:6645. [PMID: 37892785 PMCID: PMC10607208 DOI: 10.3390/jcm12206645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Direct stenting (DS) compared with conventional stenting (CS) after balloon predilatation may reduce distal embolization during percutaneous coronary intervention (PCI), thereby improving tissue reperfusion. In contrast, DS may increase the risk of stent underexpansion and target lesion failure. METHODS In this sub-study of the randomized COMPARE CRUSH trial (NCT03296540), we reviewed the efficacy of DS versus CS in a cohort of contemporary, pretreated ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. We compared DS versus CS, assessing (1) stent diameter in the culprit lesion, (2) thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery post-PCI and complete ST-segment resolution (STR) one-hour post-PCI, and (3) target lesion failure at one year. For proportional variables, propensity score weighting was applied to account for potential treatment selection bias. RESULTS This prespecified sub-study included 446 patients, of whom 189 (42%) were treated with DS. Stent diameters were comparable between groups (3.2 ± 0.5 vs. 3.2 ± 0.5 mm, p = 0.17). Post-PCI TIMI 3 flow and complete STR post-PCI rates were similar between groups (DS 93% vs. CS 90%, adjusted OR 1.16 [95% CI, 0.56-2.39], p = 0.69, and DS 72% vs. CS 58%, adjusted OR 1.29 [95% CI 0.77-2.16], p = 0.34, respectively). Moreover, target lesion failure rates at one year were comparable (DS 2% vs. 1%, adjusted OR 2.93 [95% CI 0.52-16.49], p = 0.22). CONCLUSION In this contemporary pretreated STEMI cohort, we found no difference in early myocardial reperfusion outcomes between DS and CS. Moreover, DS seemed comparable to CS in terms of stent diameter and one-year vessel patency.
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Affiliation(s)
- Rosanne F. Vogel
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Amsterdam UMC Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen M. Wilschut
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Miguel E. Lemmert
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
- Department of Cardiology, Isala Hospital, 8025 AB Zwolle, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | | | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Gilles Montalescot
- ACTION Group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Sorbonne University, 75013 Paris, France
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32610, USA
| | - Mitchell W. Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Georgios J. Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
- Department of Cardiology, Euroclinic Athens, 11521 Athens, Greece
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8
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Huebinger R, Bobrow BJ. Smarter Prehospital Clinical Trials Through a Smartphone App. Resuscitation 2023; 187:109813. [PMID: 37121461 DOI: 10.1016/j.resuscitation.2023.109813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/22/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Ryan Huebinger
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth); Texas Emergency Medicine Research Center.
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth); Texas Emergency Medicine Research Center
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9
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Rikken SAOF, Selvarajah A, Hermanides RS, Coller BS, Gibson CM, Granger CB, Lapostolle F, Postma S, van de Wetering H, van Vliet RCW, Montalescot G, Ten Berg JM, van 't Hof AWJ. Prehospital treatment with zalunfiban (RUC-4) in patients with ST- elevation myocardial infarction undergoing primary percutaneous coronary intervention: Rationale and design of the CELEBRATE trial. Am Heart J 2023; 258:119-128. [PMID: 36592878 DOI: 10.1016/j.ahj.2022.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/21/2022] [Accepted: 12/17/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND Early and complete restoration of target vessel patency in ST-elevation myocardial infarction (STEMI) is associated with improved outcomes. Oral P2Y12 inhibitors have failed to demonstrate either improved patency or reduced mortality when administered in the prehospital setting. Thus, there is a need for antiplatelet agents that achieve prompt and potent platelet inhibition, and that restore patency in the prehospital setting. Zalunfiban, a novel subcutaneously administered glycoprotein IIb/IIIa inhibitor designed for prehospital administration, has shown to achieve rapid, high-grade platelet inhibition that exceeds that of P2Y12 inhibitors. Whether prehospital administration of zalunfiban can improve clinical outcome is unknown. HYPOTHESIS The present study is designed to assess the hypothesis that a single, prehospital injection of zalunfiban given in the ambulance, in addition to standard-of-care in patients with STEMI with intent to undergo primary percutaneous coronary intervention (PCI) will improve clinical outcome compared to standard-of-care with placebo. STUDY DESIGN The ongoing CELEBRATE trial (NCT04825743) is a phase 3, randomized, double-blinded, placebo-controlled, international trial. Patients with STEMI intended to undergo primary PCI will receive treatment with a single subcutaneous injection containing either zalunfiban dose 1 (0.110 mg/kg), zalunfiban dose 2 (0.130 mg/kg) or placebo, and the study drug will be administered in the ambulance before transportation to the hospital. A target of 2499 patients will be randomly assigned to one of the treatment groups in a 1:1:1 ratio, ie, to have approximately 833 evaluable patients per group. The primary efficacy outcome is a ranked 7-point scale on clinical outcomes. The primary safety outcome is severe or life-threatening bleeding according to the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) criteria. SUMMARY The CELEBRATE trial will assess whether a single prehospital subcutaneous injection of zalunfiban in addition to standard-of-care in patients with STEMI with intent to undergo primary PCI will result in improved clinical outcome.
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Affiliation(s)
- Sem A O F Rikken
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Abi Selvarajah
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, New York, NY, United States of America
| | - C Michael Gibson
- Boston Clinical Research Institute, Boston, MA, United States of America
| | - Christopher B Granger
- Department of Cardiology, Duke University School of Medicine, Durham, NC, United States of America
| | | | | | - Henri van de Wetering
- Diagram Research, Zwolle, The Netherlands; Regional Emergency Medical Service Ijsselland, The Netherlands
| | | | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, Department of Cardiology, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Jurriën M Ten Berg
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Hospital, Heerlen, The Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands.
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10
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Delewi R, Vogel RF, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Doevendans PA, Van Mieghem NM, Smits PC, Vlachojannis GJ. Sex-stratified differences in early antithrombotic treatment response in patients presenting with ST-segment elevation myocardial infarction. Am Heart J 2023; 258:17-26. [PMID: 36596332 DOI: 10.1016/j.ahj.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND The mechanisms underlying the increased risk of bleeding that female patients with ST-segment Elevation Myocardial Infarction (STEMI) exhibit, remains unclear. The present report assessed sex-related differences in response to pre-hospital dual antiplatelet therapy (DAPT) initiation in patients with STEMI. METHODS The COMPARE CRUSH trial randomized patients presenting with STEMI to receive a pre-hospital loading dose of crushed or integral prasugrel tablets in the ambulance. In this substudy, we compared platelet reactivity levels and the occurrence of high platelet reactivity (HPR; defined as platelet reactivity ≥208) between sexes at 4 prespecified time points after DAPT initiation, and evaluated post-PCI bleeding between groups. RESULTS Out of 633 STEMI patients, 147 (23%) were female. Females compared with males presented with significantly higher levels of platelet reactivity and higher HPR rates at baseline (232 [IQR, 209-256] vs 195 [IQR, 171-220], P < .01, and 76% vs 41%, OR 4.58 [95%CI, 2.52-8.32], P < .01, respectively). Moreover, female sex was identified as the sole independent predictor of HPR at baseline (OR 5.67 [95%CI, 2.56-12.53], P < .01). Following DAPT initiation, levels of platelet reactivity and the incidence of HPR were similar between sexes. Post-PCI bleeding occurred more frequently in females compared with males (10% vs 2%, OR 6.02 [95%CI, 2.61-11.87], P < .01). Female sex was an independent predictor of post-PCI bleeding (OR 3.25 [95%CI, 1.09-9.72], P = .04). CONCLUSIONS In this contemporary STEMI cohort, female STEMI patients remain at risk of bleeding complications after primary PCI. However, this is not explained by sex-specific differences in the pharmacodynamic response to pre-hospital DAPT initiation.
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Affiliation(s)
- Ronak Delewi
- Department of cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Rosanne F Vogel
- Department of cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands; Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen M Wilschut
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Miguel E Lemmert
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Roberto Diletti
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Rutger-Jan Nuis
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Dimitrios Alexopoulos
- Department of cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- ACTION group, Sorbonne University, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France
| | | | | | - Pieter A Doevendans
- Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nicolas M Van Mieghem
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Georgios J Vlachojannis
- Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Maasstad Hospital, Rotterdam, the Netherlands.
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11
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Rikken SAOF, Storey RF, Andreotti F, Clemmensen P, Ten Berg JM. Parenteral Antiplatelet Drugs in ST-Elevation Myocardial Infarction: Current Status and Future Directions. Thromb Haemost 2023; 123:150-158. [PMID: 36075236 DOI: 10.1055/s-0042-1753479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Oral inhibitors of the platelet P2Y12 receptor are indispensable in the treatment of ST-elevation myocardial infarction (STEMI), improving outcomes and even reducing mortality in some studies. However, these drugs are limited by delayed absorption and suboptimal platelet inhibition at the time of primary percutaneous coronary intervention. Despite efforts to achieve faster and more sustained platelet inhibition, strategies such as prehospital administration, higher loading doses, and crushed formulations have not led to improved coronary reperfusion. Parenteral glycoprotein IIb/IIIa inhibitors act sooner and are more potent than oral P2Y12 inhibitors, but their use has been limited by the increased risk of major bleeding and thrombocytopenia. Hence, there is a clinical need to refine drugs that deliver rapid, effective, yet safe platelet inhibition in the setting of STEMI. Novel parenteral antiplatelet drugs, such as cangrelor, selatogrel, and zalunfiban, have been recently developed to achieve rapid, potent antiplatelet effects while preserving hemostasis. We provide a description of currently available parenteral antiplatelet agents and of those in clinical development for prehospital administration in STEMI patients.
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Affiliation(s)
- Sem A O F Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,School for Cardiovascular Diseases, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Peter Clemmensen
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany.,Department of Medicine, Nykøbing F Hospital, Nykøbing Falster, Denmark
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,School for Cardiovascular Diseases, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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12
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Franchi F, Ortega-Paz L, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Reiter B, Jilma B, Angiolillo DJ. Cangrelor in Patients With Coronary Artery Disease Pretreated With Ticagrelor: The Switching Antiplatelet (SWAP)-5 Study. JACC Cardiovasc Interv 2023; 16:36-46. [PMID: 36317958 DOI: 10.1016/j.jcin.2022.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are no studies specifically designed to rule out a drug-drug interaction (DDI) when cangrelor is used among patients who have been pretreated with ticagrelor. OBJECTIVES This study sought to rule out a DDI among cangrelor-treated patients who have been pretreated with ticagrelor. METHODS In this prospective, randomized, double-blind, placebo-controlled, crossover, pharmacokinetic (PK) and pharmacodynamic (PD) study, patients with coronary artery disease (N = 20) were pretreated with a 180-mg ticagrelor loading dose and after 1 hour randomized to placebo or cangrelor (bolus and infusion for 2 hours). Patients crossed over after 1 to 4 weeks of washout. PK analysis included ticagrelor plasma levels and its active metabolite. PD assessments included VerifyNow P2Y12 reaction units (PRU), light transmittance aggregometry, vasodilator-stimulated phosphoprotein, and Total Thrombus-Formation Analysis System. PK/PD assessments were performed at 7 time points. RESULTS Compared with placebo, adding cangrelor to patients pretreated with ticagrelor resulted in a significant reduction in PRU at 30 minutes and 1 hour after starting infusion. At 2 hours after stopping cangrelor/placebo infusion, PRU were low and similar in both groups (16.9 vs 12.6; mean difference: 4.3; 95% CI: -28.6 to 37.3), meeting the noninferiority primary endpoint (predefined noninferiority margin 45 PRU). Consistent findings were shown with all PD assays. PK tracked PD findings with no differences between groups in plasma levels of ticagrelor and its metabolite. CONCLUSIONS Compared with placebo, the use of cangrelor in patients pretreated with ticagrelor results in enhanced platelet inhibition with no differences in PK/PD profiles after discontinuation of drug infusion indicating the absence of a DDI. (PD and PK Profiles of Switching Between Cangrelor and Ticagrelor Following Ticagrelor Pre-treatment [SWAP-5]; NCT04634162).
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Birgit Reiter
- Clinical Institute of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA.
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13
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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Smits PC, Van Mieghem NM, Vlachojannis GJ. Pre-hospital treatment with crushed versus integral tablets of prasugrel in patients presenting with ST-Segment Elevation Myocardial Infarction-1-year follow-up results of the COMPARE CRUSH trial. Am Heart J 2022; 252:26-30. [PMID: 35671829 DOI: 10.1016/j.ahj.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/31/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
The present research letter reports the 1-year clinical outcomes of the randomized COMPARE CRUSH trial, which allocated STEMI patients at first medical contact in the ambulance to receive either crushed or integral tablets of prasugrel loading dose. This trial aimed to investigate whether early enhanced antiplatelet effect constituted by the crushed potent oral P2Y12 inhibitor prasugrel could lead to improved early myocardial reperfusion and clinical outcomes.
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Affiliation(s)
- Rosanne F Vogel
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel E Lemmert
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Dimitrios Alexopoulos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gilles Montalescot
- Sorbonne University, ACTION group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France
| | - Dominick J Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands.
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14
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Current and Future Insights for Optimizing Antithrombotic Therapy to Reduce the Burden of Cardiovascular Ischemic Events in Patients with Acute Coronary Syndrome. J Clin Med 2022; 11:jcm11195605. [PMID: 36233469 PMCID: PMC9573364 DOI: 10.3390/jcm11195605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
The pharmacological treatment strategies for acute coronary syndrome (ACS) in recent years are constantly evolving to develop more potent antithrombotic agents, as reflected by the introduction of more novel P2Y12 receptor inhibitors and anticoagulants to reduce the ischemic risk among ACS patients. Despite the substantial improvements in the current antithrombotic regimen, a noticeable number of ACS patients continue to experience ischemic events. Providing effective ischemic risk reduction while balancing bleeding risk remains a clinical challenge. This updated review discusses the currently approved and widely used antithrombotic agents and explores newer antithrombotic treatment strategies under development for the initial phase of ACS.
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15
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Fabris E, Korjian S, Coller BS, Ten Berg JM, Granger CB, Gibson CM, van 't Hof AWJ. Pre-Hospital Antiplatelet Therapy for STEMI Patients Undergoing Primary Percutaneous Coronary Intervention: What We Know and What Lies Ahead. Thromb Haemost 2021; 121:1562-1573. [PMID: 33677829 PMCID: PMC8604087 DOI: 10.1055/a-1414-5009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Early recanalization of the infarct-related artery to achieve myocardial reperfusion is the primary therapeutic goal in patients with ST-elevation myocardial infarction (STEMI). To decrease the duration of ischaemia, continuous efforts have been made to improve pre-hospital treatment and to target the early period after symptom onset. In this period the platelet content of the fresh coronary thrombus is maximal and the thrombi are dynamic, and thus more susceptible to powerful antiplatelet agents. There have been substantial advances in antiplatelet therapy in the last three decades with several classes of oral and intravenous antiplatelet agents with different therapeutic targets, pharmacokinetics, and pharmacodynamic properties. New parenteral drugs achieve immediate inhibition of platelet aggregation, and fast and easy methods of administration may create the opportunity to bridge the initial gap in platelet inhibition observed with oral P2Y12 inhibitors. Moreover, potential future management of STEMI could directly involve patients in the process of care with self-administered antiplatelet agents designed to achieve rapid reperfusion. However, the potential anti-ischaemic benefits of potent antiplatelet agents will need to be balanced against their risk of increased bleeding. This study presents a comprehensive and updated review of pre-hospital antiplatelet therapy among STEMI patients undergoing primary percutaneous intervention and explores new therapies under development.
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Affiliation(s)
- Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Serge Korjian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Barry S Coller
- Allen and Frances Adler Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, United States
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christopher B Granger
- Duke Clinical Research Institute and the Division of Cardiology, Duke University Medical Center, Durham, North Carolina, United States
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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16
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Bor WL, Zheng KL, Tavenier AH, Gibson CM, Granger CB, Bentur O, Lobatto R, Postma S, Coller BS, van 't Hof AWJ, Ten Berg JM. Pharmacokinetics, pharmacodynamics, and tolerability of subcutaneous administration of a novel glycoprotein IIb/IIIa inhibitor, RUC-4, in patients with ST-segment elevation myocardial infarction. EUROINTERVENTION 2021; 17:e401-e410. [PMID: 34031019 DOI: 10.4244/eij-d-21-00287] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pre-hospital platelet inhibition in patients with ST-segment elevation myocardial infarction (STEMI) may improve outcomes. RUC-4 is a novel, second-generation glycoprotein IIb/IIIa inhibitor designed for first-point-of-medical-contact treatment for STEMI by subcutaneous injection. AIMS The open-label, phase 2A, CEL-02 trial aimed to assess the pharmacodynamics (PD), pharmacokinetics (PK), and tolerability of RUC-4 in STEMI patients undergoing primary PCI (pPCI). METHODS A total of 27 STEMI patients received a weight-adjusted subcutaneous injection of RUC-4 before pPCI in escalating doses (0.075 mg/kg [n=8], 0.090 mg/kg [n=9], or 0.110 mg/kg [n=10]). RESULTS The primary PD endpoint of high-grade (≥77%) inhibition of the VerifyNow iso-TRAP assay at 15 minutes was met in 3/8, 7/8, and 7/8 patients in the three cohorts with a dose-response relationship (mean inhibition [min - max] of 77.5% [65.7%-90.6%], 87.5% [73.8%-93.1%], and 91.7% [76.4%-99.3%], respectively; ptrend=0.002). Fifty percent (50%) inhibition remained after 89.1 (38.0-129.7), 104.2 (17.6-190.8), and 112.4 (19.7-205.0) minutes. Injection site reactions or bruising were observed in 1 (4%) and 11 (41%) patients, respectively. Mild access-site haematomas occurred in 6 (22%), and severe access-site haematomas occurred in 2 patients (7%). No thrombocytopaenia was observed within 72 hours post dose. CONCLUSIONS In patients with STEMI, a single subcutaneous dose of RUC-4 at 0.075, 0.090, and 0.110 mg/kg showed dose-response high-grade inhibition of platelet function within 15 minutes.
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Affiliation(s)
- Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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17
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Kunkel KJ, Lemor A, Mahmood S, Villablanca P, Ramakrishna H. 2021 Update for the Diagnosis and Management of Acute Coronary Syndromes for the Perioperative Clinician. J Cardiothorac Vasc Anesth 2021; 36:2767-2779. [PMID: 34400062 PMCID: PMC8297970 DOI: 10.1053/j.jvca.2021.07.032] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
In this review, recent key publications related to acute coronary syndrome (ACS) are summarized and placed into context of contemporary practice. Landmark trials examining vascular access in ST-elevation myocardial infarction, the management of multivessel disease, acute myocardial infarction and cardiac arrest are discussed. An update in pharmacology for ACS provides updates in major trials relating to P2Y12 inhibitor initiation, deescalation, and use in special populations. Additional updates in the use of lipid-lowering agents and adjunctive medications in ACS are reviewed. Finally, cardiac pathology related to coronavirus disease 2019 (COVID-19), as well as the impact of the COVID-19 global pandemic on the care of patients with ACS, is summarized.
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Affiliation(s)
| | - Alejandro Lemor
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Shazil Mahmood
- Division of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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18
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Coughlan JJ, Aytekin A, Lahu S, Ndrepepa G, Menichelli M, Mayer K, Wöhrle J, Bernlochner I, Gewalt S, Witzenbichler B, Hochholzer W, Sibbing D, Cassese S, Angiolillo DJ, Hemetsberger R, Valina C, Müller A, Kufner S, Liebetrau C, Xhepa E, Hapfelmeier A, Sager HB, Joner M, Fusaro M, Richardt G, Laugwitz KL, Neumann FJ, Schunkert H, Schüpke S, Kastrati A. Ticagrelor or Prasugrel for Patients With Acute Coronary Syndrome Treated With Percutaneous Coronary Intervention: A Prespecified Subgroup Analysis of a Randomized Clinical Trial. JAMA Cardiol 2021; 6:1121-1129. [PMID: 34190967 DOI: 10.1001/jamacardio.2021.2228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance It is unclear whether ticagrelor or prasugrel hydrochloride is superior for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). Objective To assess the safety and efficacy of ticagrelor vs prasugrel for patients with ACS treated with PCI. Design, Setting, and Participants A prespecified analysis was performed of a postrandomization subgroup of 3377 patients who presented with ACS and were treated with PCI in the investigator-initiated, multicenter, phase 4, open-label Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5 randomized clinical trial, conducted from September 1, 2013, to February 28, 2018. Statistical analysis was performed from September 1, 2020, to January 30, 2021. Analysis was performed according to the intention-to-treat principle. Interventions Patients were randomly assigned to a ticagrelor-based or prasugrel-based strategy. This analysis focuses on the subgroup of patients who underwent PCI that was formed after randomization. Main Outcomes and Measures The primary end point was a composite consisting of all-cause death, myocardial infarction, or stroke at 12 months. The safety end point was Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding. Results The ticagrelor group comprised 1676 patients (1323 men [78.9%]; mean [SD] age, 64.4 [12.0] years), and the prasugrel group comprised 1701 patients (1341 men [78.8%]; mean [SD] age, 64.7 [12.0] years). The primary end point occurred for 162 patients (9.8%) in the ticagrelor group and 120 patients (7.1%) in the prasugrel group (hazard ratio [HR], 1.41; 95% CI, 1.11-1.78; P = .005). Myocardial infarction occurred in 88 patients (5.3%) in the ticagrelor group compared with 55 patients (3.8%) in the prasugrel group (HR, 1.67; 95% CI, 1.19-2.34; P = .003). The safety end point, BARC type 3 to 5 bleeding, occurred in 84 of 1672 patients (5.3%) in the ticagrelor group and 78 of 1680 patients (4.9%) in the prasugrel group (HR; 1.10; 95% CI, 0.81-1.50; P = .54). Conclusions and Relevance Among patients presenting with ACS who were treated with PCI, the incidence of the primary composite end point occurred less frequently for patients who received prasugrel compared with those who received ticagrelor. The incidence of bleeding events was comparable between the 2 groups. These results suggest that, for patients presenting with ACS who undergo PCI, a prasugrel-based strategy is superior to a ticagrelor-based strategy. However, because these observations are based on a postrandomization subgroup, these findings should be regarded as hypothesis generating and dedicated randomized clinical trials may be warranted to confirm these findings. Trial Registration ClinicalTrials.gov Identifier: NCT01944800.
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Affiliation(s)
- J J Coughlan
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alp Aytekin
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Shqipdona Lahu
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gjin Ndrepepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Katharina Mayer
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Jochen Wöhrle
- Department of Cardiology, Medical Campus Lake Constance, Friedrichshafen, Germany
| | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Senta Gewalt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany.,Department of Cardiology, Klinik der Universität München, Ludwig-Maximilians-University, Munich, Germany
| | - Salvatore Cassese
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Arne Müller
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany
| | - Sebastian Kufner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Christoph Liebetrau
- Heart Center, Campus Kerckhoff of Justus-fLiebig-University, Giessen, Germany
| | - Erion Xhepa
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich School of Medicine, Munich, Germany.,School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
| | - Hendrik B Sager
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Massimiliano Fusaro
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gert Richardt
- Department of Cardiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Karl Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Franz Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
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19
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Vogel RF, Delewi R, Angiolillo DJ, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Krucoff MW, van Mieghem NM, Smits PC, Vlachojannis GJ. Pharmacodynamic Effects of Pre-Hospital Administered Crushed Prasugrel in Patients With ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2021; 14:1323-1333. [PMID: 34167672 DOI: 10.1016/j.jcin.2021.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/01/2021] [Accepted: 04/09/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES This study sought to compare the pharmacodynamic effects of pre-hospitally administered P2Y12 inhibitor prasugrel in crushed versus integral tablet formulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). BACKGROUND Early dual antiplatelet therapy is recommended in STEMI patients. Yet, onset of oral P2Y12 inhibitor effect is delayed and varies according to formulation administered. METHODS The COMPARE CRUSH (Comparison of Pre-hospital Crushed Versus Uncrushed Prasugrel Tablets in Patients With STEMI Undergoing Primary Percutaneous Coronary Interventions) trial randomized patients with suspected STEMI to crushed or integral prasugrel 60-mg loading dose in the ambulance. Pharmacodynamic measurements were performed at 4 time points: before antiplatelet treatment, at the beginning and end of pPCI, and 4 h after study treatment onset. The primary endpoint was high platelet reactivity at the end of pPCI. The secondary endpoint was impact of platelet reactivity status on markers of coronary reperfusion. RESULTS A total of 441 patients were included. In patients with crushed prasugrel, the occurrence of high platelet reactivity at the end of pPCI was reduced by almost one-half (crushed 34.7% vs. uncrushed 61.6%; odds ratio [OR] = 0.33; 95% confidence interval [CI] = 0.22 to 0.50; p < 0.01). Platelet reactivity <150 P2Y12 reactivity units at the beginning of coronary angiography correlated with improved Thrombolysis In Myocardial Infarction flow grade 3 in the infarct artery pre-pPCI (OR: 1.78; 95% CI: 1.08 to 2.94; p = 0.02) but not ST-segment resolution (OR: 0.80; 95% CI: 0.48 to 1.34; p = 0.40). CONCLUSIONS Oral administration of crushed compared with integral prasugrel significantly improves platelet inhibition during the acute phase in STEMI patients undergoing pPCI. However, a considerable number of patients still exhibit inadequate platelet inhibition at the end of pPCI, suggesting the need for alternative agents to bridge the gap in platelet inhibition.
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Affiliation(s)
- Rosanne F Vogel
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dominick J Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Miguel E Lemmert
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Dimitrios Alexopoulos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- Department of Cardiology, ACTION Group, Groupe Hospitalier Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Sorbonne University, Paris, France
| | - Mitchell W Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands.
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20
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Chatterjee A, Skinner K. Crushed Prasugrel Improves Pharmacodynamics But Little Else: Where Are the Missing Pieces? JACC Cardiovasc Interv 2021; 14:1334-1336. [PMID: 34167673 DOI: 10.1016/j.jcin.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Arka Chatterjee
- Division of Cardiology, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA.
| | - Kristina Skinner
- Division of Cardiology, Sarver Heart Center, University of Arizona College of Medicine, Tucson, Arizona, USA
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21
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Capranzano P, Angiolillo DJ. Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:519-535. [PMID: 33881367 DOI: 10.1080/14779072.2021.1920925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Oral P2Y12 inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y12 inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y12 inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y12 inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y12 inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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22
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Kearney A, Linden K, Savage P, Menown IBA. Advances in Clinical Cardiology 2020: A Summary of Key Clinical Trials. Adv Ther 2021; 38:2170-2200. [PMID: 33844133 PMCID: PMC8040014 DOI: 10.1007/s12325-021-01711-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/12/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Despite the challenge of a global pandemic, 2020 has been an invaluable year in cardiology research with numerous important clinical trials published or presented virtually at major international meetings. This article aims to summarise these trials and place them in clinical context. METHODS The authors reviewed clinical trials presented at major cardiology conferences during 2020 including the American College of Cardiology, European Association for Percutaneous Cardiovascular Interventions, European Society of Cardiology, Transcatheter Cardiovascular Therapeutics and the American Heart Association. Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. RESULTS A total of 87 key cardiology clinical trials were identified for inclusion. New interventional and structural cardiology data included trials evaluating bifurcation percutaneous coronary intervention (PCI) techniques, intravascular ultrasound (IVUS)-guided PCI, instantaneous wave-free (iFR) physiological assessment, new generation stents (DynamX bioadaptor), transcatheter aortic valve implantation (TAVI) in low-risk patients, and percutaneous mitral or tricuspid valve interventions. Preventative cardiology data included new data with proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab), omega-3 supplements, evinacumab and colchicine in the setting of chronic coronary artery disease. Antiplatelet data included trials evaluating both the optimal length of course following PCI and combination of antiplatelet agents and regimes including combination antithrombotic therapies for patients with atrial fibrillation (AF). Heart failure data included the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors (sotagliflozin, empagliflozin and dapagliflozin) and mavacamten in hypertrophic cardiomyopathy. Electrophysiology trials included early rhythm control in AF and screening for AF. CONCLUSION This article presents a summary of key clinical cardiology trials during the past year and should be of relevance to both clinicians and cardiology researchers.
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Affiliation(s)
- Aileen Kearney
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Katie Linden
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Patrick Savage
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Ian B A Menown
- Craigavon Cardiac Centre, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK.
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23
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Voll F, Kuna C, Ndrepepa G, Kastrati A, Cassese S. Antithrombotic treatment in primary percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:313-324. [PMID: 33705211 DOI: 10.1080/14779072.2021.1902807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite a timely mechanical reperfusion with primary percutaneous coronary intervention (pPCI) patients presenting with ST-elevation myocardial infarction (STEMI) display an increased risk of adverse cardiovascular events. Several studies have demonstrated that guideline-directed antithrombotic therapy is effective to reduce this risk. However, there is still much to be accomplished to improve antithrombotic therapies in this clinical setting. AREAS COVERED This paper reviews current data on antithrombotic therapy in STEMI patients undergoing pPCI. EXPERT OPINION Antithrombotic therapy for STEMI patients undergoing pPCI should take into account the variability of thrombotic and bleeding risk in the short and long term. Patients with STEMI profit from the administration of early onset antiplatelet agents and anticoagulation to achieve sufficient and predictable antithrombotic effect at the time of pPCI. Thereafter, antithrombotic therapies should be tailored to individual risk of recurrence over the long term, to avoid excess bleeding, while ensuring adequate secondary ischemic prevention.
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Affiliation(s)
- Felix Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Constantin Kuna
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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24
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Alfonso F, Gonzalo N, Rivero F, Escaned J. The year in cardiovascular medicine 2020: interventional cardiology. Eur Heart J 2021; 42:985-1003. [PMID: 33448291 PMCID: PMC7928953 DOI: 10.1093/eurheartj/ehaa1096] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Fernando Alfonso
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Nieves Gonzalo
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
| | - Fernando Rivero
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Javier Escaned
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
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25
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Medranda GA, Case BC, Wermers JP, Morrison N, Yerasi C, Forrestal B, Chezar-Azerrad C, Waksman R. Review of Coronary Late Breaking Trials From the TCT Connect 2020 Virtual Meeting. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28:65-70. [PMID: 33707152 PMCID: PMC8065258 DOI: 10.1016/j.carrev.2020.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Giorgio A Medranda
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Natalie Morrison
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Charan Yerasi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Brian Forrestal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Chava Chezar-Azerrad
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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26
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Guedeney P, Collet JP. Antithrombotic Therapy in Acute Coronary Syndromes: Current Evidence and Ongoing Issues Regarding Early and Late Management. Thromb Haemost 2021; 121:854-866. [PMID: 33506483 DOI: 10.1055/s-0040-1722188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y12 inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y12 inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y12 inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
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27
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Tavenier AH, Hermanides RS, Fabris E, Angiolillo DJ, van 't Hof AWJ. Bridging the gap: Current and future insights for improving suboptimal platelet inhibition in STEMI. Int J Cardiol 2020; 328:40-45. [PMID: 33242504 DOI: 10.1016/j.ijcard.2020.11.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/31/2020] [Accepted: 11/17/2020] [Indexed: 01/31/2023]
Abstract
Antiplatelet therapy is one of the cornerstones in the acute treatment of patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI). However, hemodynamic changes and delayed intestinal absorption of P2Y12 inhibitors leads to a delay in the onset of antiplatelet effects resulting in a gap of platelet inhibition. Several strategies have been proposed to bridge this gap, such as pre-hospital administration of antiplatelet therapy, higher loading doses of P2Y12 inhibitors, crushing or chewing tablets, subcutaneous or intravenous administration of platelet inhibitors, or use of pain relievers alternative to opioids that do not delay intestinal absorption of oral platelet inhibitors. These strategies may improve platelet inhibition with the goal of optimizing clinical outcomes in the acute phase of STEMI. In this review we present current and future insights for bridging the gap in platelet inhibition in STEMI patients undergoing primary PCI.
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Affiliation(s)
| | | | - Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Arnoud W J van 't Hof
- Department of Cardiology, Isala, Zwolle, the Netherlands; Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
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