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Kim HS, Kang J, Stefanini G, De Caterina R. Antiplatelet monotherapy after DAPT: is clopidogrel the new standard? Pros and cons. EUROINTERVENTION 2024; 20:e737-e739. [PMID: 38887879 DOI: 10.4244/eij-e-24-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Affiliation(s)
- Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul, Republic of Korea
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Raffaele De Caterina
- University of Pisa and Cardiovascular Division 1, Pisa University Hospital, Pisa, Italy
- Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
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2
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Herron GC, Bates ER. Review of the Ticagrelor Trials Evidence Base. J Am Heart Assoc 2024; 13:e031606. [PMID: 38804216 DOI: 10.1161/jaha.123.031606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.
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Affiliation(s)
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine University of Michigan Ann Arbor MI USA
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3
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Li Y, Li J, Wang B, Jing Q, Zeng Y, Hou A, Wang Z, Liu A, Zhang J, Zhang Y, Zhang P, Jiang D, Liu B, Fan J, Zhang J, Li L, Su G, Yang M, Jiang W, Qu P, Zeng H, Li L, Qiu M, Ru L, Chen S, Zhou Y, Qiao S, Stone GW, Angiolillo DJ, Han Y. Extended Clopidogrel Monotherapy vs DAPT in Patients With Acute Coronary Syndromes at High Ischemic and Bleeding Risk: The OPT-BIRISK Randomized Clinical Trial. JAMA Cardiol 2024; 9:523-531. [PMID: 38630489 PMCID: PMC11024736 DOI: 10.1001/jamacardio.2024.0534] [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: 07/04/2023] [Accepted: 02/02/2024] [Indexed: 04/20/2024]
Abstract
Importance Purinergic receptor P2Y12 (P2Y12) inhibitor monotherapy after a certain period of dual antiplatelet therapy (DAPT) may be an attractive option of maintenance antiplatelet treatment for patients undergoing percutaneous coronary intervention (PCI) who are at both high bleeding and ischemic risk (birisk). Objective To determine if extended P2Y12 inhibitor monotherapy with clopidogrel is superior to ongoing DAPT with aspirin and clopidogrel after 9 to 12 months of DAPT after PCI in birisk patients with acute coronary syndromes (ACS). Design, Setting, and Participants This was a multicenter, double-blind, placebo-controlled, randomized clinical trial including birisk patients with ACS who had completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months at 101 China centers between February 2018 and December 2020. Study data were analyzed from April 2023 to May 2023. Interventions Patients were randomized either to clopidogrel plus placebo or clopidogrel plus aspirin for an additional 9 months. Main Outcomes and Measures The primary end point was Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding 9 months after randomization. The key secondary end point was major adverse cardiac and cerebral events (MACCE; the composite of all-cause death, myocardial infarction, stroke or clinically driven revascularization). The primary end point was tested for superiority, and the MACCE end point was tested for sequential noninferiority and superiority. Results A total of 7758 patients (mean [SD] age, 64.8 [9.0] years; 4575 male [59.0%]) were included in this study. The primary end point of BARC types 2, 3, or 5 bleeding occurred in 95 of 3873 patients (2.5%) assigned to clopidogrel plus placebo and 127 of 3885 patients (3.3%) assigned to clopidogrel plus aspirin (hazard ratio [HR], 0.75; 95% CI, 0.57-0.97; difference, -0.8%; 95% CI, -1.6% to -0.1%; P = .03). The incidence of MACCE was 2.6% (101 of 3873 patients) in the clopidogrel plus placebo group and 3.5% (136 of 3885 patients) in the clopidogrel plus aspirin group (HR, 0.74; 95% CI, 0.57-0.96; difference, -0.9%; 95% CI, -1.7% to -0.1%; P < .001 for noninferiority; P = .02 for superiority). Conclusions and Relevance Among birisk patients with ACS who completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months before randomization, an extended 9-month clopidogrel monotherapy regimen was superior to continuing DAPT with clopidogrel in reducing clinically relevant bleeding without increasing ischemic events. Trial Registration ClinicalTrials.gov Identifier: NCT03431142.
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Affiliation(s)
- Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Wang
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanmin Jing
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Yujie Zeng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aijie Hou
- The People’s Hospital of Liaoning Province, Shenyang, China
| | | | - Aijun Liu
- Benxi Central Hospital, Benxi, China
| | | | | | - Ping Zhang
- Beijing Tsinghua Changgung Hospital, Beijing, China
| | | | - Bin Liu
- The Second Hospital of Jilin University, Changchun, China
| | | | - Jun Zhang
- Cangzhou Central Hospital, Cangzhou, China
| | - Li Li
- Guangzhou Red Cross Hospital, Guangzhou, China
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical University, Ji’nan, China
| | - Ming Yang
- Yingkou Central Hospital, Yingkou, China
| | - Weihong Jiang
- The Third Xiangya Hospital of Central South University, Changsha, China
| | - Peng Qu
- The Second Hospital of Dalian Medical University, Dalian, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Lu Li
- The Second Affiliated Hospital of Shenyang Medical College, Shenyang, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Leisheng Ru
- Bethune International Peace Hospital, Shijiazhuang, China
| | | | - Yujie Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shubin Qiao
- Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
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De Servi S, Landi A, Savonitto S. Clopidogrel induced reduction in neutrophil count: An overlooked beneficial effect? Eur J Intern Med 2024; 124:32-34. [PMID: 38582734 DOI: 10.1016/j.ejim.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/02/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Complement-stimulated neutrophils are able to adhere to the endothelium and damage endothelial cells both in vitro and in vivo. These blood cells participate in the early stages, growth and complications of atherosclerotic plaques. Recent findings, based on mendelian randomization analysis, support the concept that high neutrophil counts are a causal risk factor for ischemic heart disease and myocardial infarction . Clopidogrel decreases leukocyte count and inflammatory markers in patients with acute coronary syndromes; this off-target effect, which is independent of the antiplatelet action, may help explaining secondary prevention data showing a superiority of clopidogrel over aspirin in reducing new cardiovascular events.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), University of Italian Switzerland, CH-6900, Lugano, Switzerland
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Ishida M, Shimada R, Takahashi F, Niiyama M, Ishisone T, Matsumoto Y, Taguchi Y, Osaki T, Nishiyama O, Endo H, Sakamoto R, Tanaka K, Koeda Y, Kimura T, Goto I, Ninomiya R, Sasaki W, Itoh T, Morino Y. One-Month Dual Antiplatelet Therapy Followed by P2Y 12 Inhibitor Monotherapy After Biodegradable Polymer Drug-Eluting Stent Implantation - The REIWA Region-Wide Registry. Circ J 2024; 88:876-884. [PMID: 38569870 DOI: 10.1253/circj.cj-24-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
BACKGROUND The safety and feasibility of using 1-month dual antiplatelet therapy (DAPT) followed by P2Y12inhibitor monotherapy for patients after percutaneous coronary intervention (PCI) with thin-strut biodegradable polymer drug-eluting stents (BP-DES) in daily clinical practice remain uncertain.Methods and Results: The REIWA region-wide registry is a prospective study conducted in 1 PCI center and 9 local hospitals in northern Japan. A total of 1,202 patients who successfully underwent final PCI using BP-DES (Synergy: n=400; Ultimaster: n=401; Orsiro: n=401), were enrolled in the registry, and received 1-month DAPT followed by P2Y12inhibitor (prasugrel 3.75 mg/day or clopidogrel 75 mg/day) monotherapy. The primary endpoint was a composite of cardiovascular and bleeding events at 12 months, including cardiovascular death, myocardial infarction (MI), definite stent thrombosis (ST), ischemic or hemorrhagic stroke, and Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding. Based on the results of a previous study, we set the performance goal at 5.0%. Over the 1-year follow-up, the primary endpoint occurred in 3.08% of patients, which was lower than the predefined performance goal (Pnon-inferiority<0.0001). Notably, definite ST occurred in only 1 patient (0.08%) within 1 year (at 258 days). No differences were observed in the primary endpoint between stent types. CONCLUSIONS The REIWA region-wide registry suggests that 1-month DAPT followed by P2Y12inhibitor monotherapy is safe and feasible for Japanese patients with BP-DES.
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Affiliation(s)
- Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Ryutaro Shimada
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Ofunato Hospital
| | - Fumiaki Takahashi
- Division of Medical Engineering, Department of Information Science, Iwate Medical University
| | | | - Takenori Ishisone
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Chubu Hospital
| | - Yuki Matsumoto
- Department of Cardiology, Iwate Prefectural Ofunato Hospital
- Department of Cardiology, Iwate Prefectural Kuji Hospital
| | - Yuya Taguchi
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Miyako Hospital
| | - Takuya Osaki
- Department of Cardiology, Iwate Prefectural Kuji Hospital
| | | | - Hiroshi Endo
- Department of Cardiology, Iwate Prefectural Iwai Hospital
| | | | | | - Yorihiko Koeda
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Takumi Kimura
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Iwao Goto
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Ryo Ninomiya
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Ofunato Hospital
| | - Wataru Sasaki
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Andreotti F, O'Donoghue ML, Ten Berg JM. The year in cardiovascular medicine 2023: the top 10 papers in thrombosis and antithrombotic treatment. Eur Heart J 2024; 45:1727-1729. [PMID: 38486368 DOI: 10.1093/eurheartj/ehae123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Catholic University Medical School, Cardio-Respiratory Department, Largo F. Vito 1, 00168 Rome, Italy
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, the Netherlands
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Savage P, Cox B, Shahmohammadi M, Kelly B, Menown I. Advances in Clinical Cardiology 2023: A Summary of Key Clinical Trials. Adv Ther 2024:10.1007/s12325-024-02877-y. [PMID: 38743242 DOI: 10.1007/s12325-024-02877-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Over the course of 2023, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. METHODS The authors collated and reviewed clinical trials presented at major cardiology conferences during 2023 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. RESULTS A total of 80 key cardiology clinical trials were identified for inclusion. Key trials in acute coronary syndrome (ACS) and antiplatelet management such as HOST-IDEA, T-PASS and STOP-DAPT3 were included in addition to several pivotal interventional trials such as ORBITA 2, MULTISTARS-AMI, ILUMIEN-IV, OCTIVUS and OCTOBER. Additionally, several trials evaluated new stent design and technology such as BIOSTEMI, PARTHENOPE and TRANSFORM. Structural intervention trials included long-term data from PARTNER 3, new data on the durability of transcatheter aortic valve intervention (TAVI), in addition to major new trials regarding transcatheter tricuspid valve intervention from TRISCEND II. Heart failure (HF) and prevention covered several key studies including DAPA-MI, STEP-HF, ADVOR, DICTATE HF and CAMEO-DAPA. In cardiac devices and electrophysiology, several trial exploring novel ablation strategies in atrial fibrillation (AF) such as PULSED AF and ADVENT were presented with further data evaluating the efficacy of anticoagulation in subclinical AF in NOAH-AFNET 6, FRAIL AF and AZALEA-TIMI 71. CONCLUSION This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.
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Affiliation(s)
- Patrick Savage
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK.
| | - Brian Cox
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Michael Shahmohammadi
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Bronagh Kelly
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
| | - Ian Menown
- Craigavon Cardiology Department, Southern Health and Social Care Trust, Craigavon, Northern Ireland, UK
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Ambrosini AP, Fishman ES, Damluji AA, Nanna MG. Chronic Coronary Disease in Older Adults. Med Clin North Am 2024; 108:581-594. [PMID: 38548465 PMCID: PMC11040602 DOI: 10.1016/j.mcna.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.
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Affiliation(s)
| | - Emily S Fishman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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Patel PP, Fanaroff AC. Optimal Medical Therapy for Chronic Coronary Disease in 2024: Focus on Antithrombotic Therapy. Med Clin North Am 2024; 108:489-507. [PMID: 38548459 DOI: 10.1016/j.mcna.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Antiplatelet therapy is the cornerstone of the secondary prevention of cardiovascular disease. Aspirin is indicated for all patients with chronic coronary disease to prevent recurrent ischemic events. A more potent antithrombotic therapy-including P2Y12 inhibitor monotherapy, dual antiplatelet therapy, or vascular dose anticoagulation-reduces the risk of ischemic events but also increases bleeding risk. Clinicians must weigh both ischemic risks and bleeding risks when determining an optimal antithrombotic therapy for patients with chronic coronary disease, and soliciting patient involvement in shared decision-making is critical.
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Affiliation(s)
- Parth P Patel
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine, Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Spirito A, Krishnan SL, Capodanno D, Angiolillo DJ, Mehran R. Antiplatelet De-Escalation Strategies in Patients Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2024; 17:e013263. [PMID: 38626078 DOI: 10.1161/circinterventions.123.013263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
Dual antiplatelet therapy-the combination of aspirin and a P2Y12 inhibitor-remains the standard antiplatelet regimen recommended to prevent ischemic complications immediately after percutaneous coronary intervention. Nonetheless, recent advances in stent technologies, percutaneous coronary intervention techniques, adjunctive pharmacotherapy for secondary prevention, and the rising awareness of the prognostic impact of bleeding, which are inevitably associated with dual antiplatelet therapy, led to the investigation of alternative antiplatelet regimens related to fewer bleeding and a preserved ischemic protection. Thrombotic complications occur mostly in the first months after percutaneous coronary intervention, while the risk of bleeding remains stable over time; this observation laid the foundation of the concept of antiplatelet de-escalation, consisting of a more intense antiplatelet regimen early after percutaneous coronary intervention, followed by a less potent antiplatelet therapy thereafter. According to new definitions proposed by the Academic Research Consortium, de-escalation can be achieved by discontinuation of 1 antiplatelet agent, switching from a potent P2Y12 inhibitor to clopidogrel, or by reducing the dose of antiplatelet agents. This review discusses the rationale and the evidence supporting antiplatelet de-escalation, provides practical guidance to use these new regimens, and gives insights into future developments in the field.
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Affiliation(s)
- Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (A.S., S.L.K., R.M.)
| | - Sriya L Krishnan
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (A.S., S.L.K., R.M.)
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," Catania, Italy (D.C.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (A.S., S.L.K., R.M.)
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Gatto L, Scalia L, Biccirè FG, Prati F. Controversy in cardiology: clopidogrel or acetylsalicylic acid in the treatment of chronic coronary syndromes? Eur Heart J Suppl 2024; 26:i74-i77. [PMID: 38784152 PMCID: PMC11110453 DOI: 10.1093/eurheartjsupp/suae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Secondary prevention of patients with chronic coronary syndrome is based on the long-term use of a single anti-aggregating drug which is traditionally represented by acetylsalicylic acid (ASA) in light of the results of studies and meta-analyses which have demonstrated a clear anti-ischaemic efficacy against of an acceptable increase in the risk of bleeding, especially intracranial and gastrointestinal bleeding. The availability of drugs such as clopidogrel, which inhibits platelet activity through the P2Y12 receptor pathway, has called into question this paradigm, also in consideration of the fact that the scientific evidence that supports the use of ASA in secondary prevention is based on dated studies with some limitations. Over the last few years, randomized trials have demonstrated how clopidogrel has an efficacy profile comparable to that of ASA and a safety profile that is sometimes even better. In light of the new evidence, it is therefore legitimate to ask whether in this clinical scenario, ASA should still be considered the drug of choice or whether clopidogrel could represent the preferable alternative.
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Affiliation(s)
- Laura Gatto
- Cardiothoracic Department, San Giovanni-Addolorata Hospital, Rome
- Center for the Fight against Heart Attack, ONLUS Foundation, Rome
| | - Lorenzo Scalia
- Center for the Fight against Heart Attack, ONLUS Foundation, Rome
- Cardiology, Umberto I Hospital—Enna Kore University, Enna
| | - Flavio Giuseppe Biccirè
- Cardiothoracic Department, San Giovanni-Addolorata Hospital, Rome
- Center for the Fight against Heart Attack, ONLUS Foundation, Rome
| | - Francesco Prati
- Cardiothoracic Department, San Giovanni-Addolorata Hospital, Rome
- Center for the Fight against Heart Attack, ONLUS Foundation, Rome
- UniCamillus—Saint Camillus International University of Health Sciences, Rome
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12
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Zhu W, Wang S, Zhang L, Xie FQ, Cheng J, Li XK, Chen W, Yan SY, Feng QM. Efficacy and safety of Tongxin formula after stent implantation for acute coronary syndrome: A multicenter, double-blind, placebo-controlled randomized trial. Explore (NY) 2024:S1550-8307(24)00055-7. [PMID: 38503613 DOI: 10.1016/j.explore.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/25/2024] [Accepted: 02/29/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE The aim of this study is to comprehensively evaluate both the efficacy and safety profile of integrating the Tongxin formula with optimal medical therapy (OMT) for patients experiencing acute coronary syndromes subsequent to coronary stenting, over the course of one year. METHODS We enrolled 150 patients diagnosed with acute coronary syndromes who had received stent placement within one month and exhibited a TCM syndrome characterized by Qi deficiency and blood stasis. This group comprised patients with unstable angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction. The participants were divided equally, allocating 75 to the Tongxin formula group and 75 to a placebo-controlled group. After undergoing percutaneous coronary intervention (PCI) surgery, both groups received conventional Western medical care, including dual antiplatelet therapy and lipid-lowering medications. The placebo-controlled group received a placebo, while the Tongxin formula group were administered Tongxin formula granules orally. Both study cohorts were monitored for a duration of 6 months. The primary endpoints included the occurrence of major adverse cardiovascular events and the rate of lumen diameter reduction post-treatment in both groups, with the Seattle Angina Scale serving as a secondary assessment tool. Safety evaluations encompassed the measurement of liver and kidney function, coagulation parameters, and other relevant indicators. RESULTS The rate of adverse cardiovascular events in the placebo-controlled group was 42.46 % within a year of surgery, whereas it was 16.90 % in the Tongxin formula group (P < 0.05). Comparing the Tongxin formula group to the placebo-controlled group, there was a decrease in the frequency of unstable angina and readmission due to cardiovascular events (P < 0.05). Coronary angiography performed 6 months after surgery revealed that the Tongxin formula group had considerably less lumen loss than the placebo-controlled group in a number of segments, including the entire segment, within the stent, at the proximal end, and at the distal end (P < 0.05). Six months after surgery, the Seattle angina score was higher in the Tongxin formula group than in the placebo-controlled group (P < 0.05). There were no significant changes in indicators such as liver and renal function as well as coagulation indexes in both groups within the first 12 months after surgery (P > 0.05). CONCLUSION Tongxin formula has been shown to lower the occurrence of major adverse cardiovascular events, minimize narrowing of blood vessel lumen, enhance clinical symptoms, and enhance the quality of life of patients following PCI surgery, all while maintaining a good safety profile.
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Affiliation(s)
- Wen Zhu
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiang Middle Road Jing 'an District, Shanghai 200071, China
| | - Su Wang
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiang Middle Road Jing 'an District, Shanghai 200071, China
| | - Lei Zhang
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiang Middle Road Jing 'an District, Shanghai 200071, China
| | - Feng-Qun Xie
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiang Middle Road Jing 'an District, Shanghai 200071, China
| | - Jie Cheng
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiang Middle Road Jing 'an District, Shanghai 200071, China
| | - Xian-Kai Li
- Department of Cardiology, Tenth People's Hospital, Tongji University, Shanghai 200072, China
| | - Wei Chen
- Department of Cardiology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Shi-Yun Yan
- Institute of Science, Technology and Humanities, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Qi-Mao Feng
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiang Middle Road Jing 'an District, Shanghai 200071, China.
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13
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Capranzano P, Moliterno D, Capodanno D. Aspirin-free antiplatelet strategies after percutaneous coronary interventions. Eur Heart J 2024; 45:572-585. [PMID: 38240716 DOI: 10.1093/eurheartj/ehad876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/20/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a platelet P2Y12 receptor inhibitor is the standard antithrombotic treatment after percutaneous coronary interventions (PCI). Several trials have challenged guideline-recommended DAPT after PCI by testing the relative clinical effect of an aspirin-free antiplatelet approach-consisting of P2Y12 inhibitor monotherapy after a short course (mostly 1-3 months) of DAPT-among patients undergoing PCI without a concomitant indication for oral anticoagulation (OAC). Overall, these studies have shown P2Y12 inhibitor monotherapy after short DAPT to be associated with a significant reduction in the risk of bleeding without an increase in thrombotic or ischaemic events compared with continued DAPT. Moreover, the effects of the P2Y12 inhibitor monotherapy without prior DAPT or following a very short course of DAPT after PCI are being investigated in emerging studies, of which one has recently reported unfavourable efficacy results associated with the aspirin-free approach compared with conventional DAPT. Finally, P2Y12 inhibitor alone has been compared with aspirin alone as chronic therapy after DAPT discontinuation, thus challenging the historical role of aspirin as a standard of care for secondary prevention following PCI. A thorough understanding of study designs, populations, treatments, results, and limitations of trials testing P2Y12 inhibitor monotherapy vs. DAPT or vs. aspirin is required to consider adopting this treatment in clinical practice. This review addresses the use of aspirin-free antiplatelet strategies among patients undergoing PCI without a concomitant indication for OAC, providing an overview of clinical evidence, guideline indications, practical implications, ongoing issues, and future perspectives.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
| | - David Moliterno
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, The University of Kentucky, Lexington, KY, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
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14
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Apostolos A, Chlorogiannis DD, Chrysostomidis G, Bozika M, Timpilis F, Kramvis A, Karamasis GV, Leventopoulos G, Davlouros P, Tsigkas G. Efficacy and Safety of Thirty-Day Dual-Antiplatelet Therapy Following Complex Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2024; 11:43. [PMID: 38392257 PMCID: PMC10889500 DOI: 10.3390/jcdd11020043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
The optimal duration of DAPT after complex PCI remains under investigation. The purpose of this systematic review and meta-analysis was to explore the safety and efficacy of a one-month therapy period versus a longer duration of DAPT after complex PCI. We systematically screened three major databases, searching for randomized controlled trials or sub-analyses of them, which compared shortened DAPT (S-DAPT), namely, one month, and longer DAPT (L-DAPT), namely, more than three months. The primary endpoint was any Net Adverse Clinical Event (NACE), and the secondary was any MACE (Major Adverse Cardiac Event), its components (mortality, myocardial infarction, stroke, and stent thrombosis), and major bleeding events. Three studies were included in the analysis, with a total of 6275 patients. Shortening DAPT to 30 days after complex PCI did not increase the risk of NACEs (OR: 0.77, 95% CI: 0.52-1.14), MACEs, mortality, myocardial infractions, stroke, or stent thrombosis. Pooled major bleeding incidence was reduced, but this finding was not statistically significant. This systematic review and meta-analysis showed that one-month DAPT did not differ compared to a longer duration of DAPT after complex PCI in terms of safety and efficacy endpoints. Further studies are still required to confirm these findings.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | | | | | - Maria Bozika
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Filippos Timpilis
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Angelos Kramvis
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Grigoris V Karamasis
- Second Cardiology Department, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 124 62 Athens, Greece
| | | | - Periklis Davlouros
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
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15
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Spirito A, Cao D, Sartori S, Sharma A, Smith KF, Vogel B, Kamaleldin K, Koshy AN, Feng Y, Power D, Baber U, Krishnamoorthy P, Dangas G, Kini A, Sharma SK, Mehran R. Predictive value of the thrombotic risk criteria proposed in the 2023 ESC guidelines for the management of ACS: insights from a large PCI registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:11-19. [PMID: 37742213 DOI: 10.1093/ehjcvp/pvad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
AIM To assess the value of the thrombotic risk criteria proposed in the 2023 guidelines of the European Society of Cardiology (ESC) for the management of acute coronary syndrome (ACS) to predict the ischaemic risk after percutaneous coronary intervention (PCI). METHODS AND RESULTS Consecutive patients with acute or chronic coronary syndrome undergoing PCI at a large tertiary-care center from 2014 to 2019 were included. Patients were stratified into low, moderate, or high thrombotic risk based on the ESC criteria. The primary endpoint was major adverse cardiovascular events (MACEs) at 1 year, a composite of all-cause death, myocardial infarction (MI), and stroke. Secondary endpoints included major bleeding. Among 11 787 patients, 2641 (22.4%) were at low-risk, 5286 (44.8%) at moderate risk, and 3860 (32.7%) at high-risk. There was an incremental risk of MACE at 1 year in patients at moderate (hazard ratios (HR) 2.53, 95% confidence interval (CI) 1.78-3.58) and high-risk (HR 3.39, 95% CI 2.39-4.80) as compared to those at low-risk, due to higher rates of all-cause death and MI. Major bleeding rates were increased in high-risk patients (HR 1.59, 95% CI 1.25-2.02), but similar between the moderate and low-risk group. The Harrell's C-index for MACE was 0.60. CONCLUSION The thrombotic risk criteria of the 2023 ESC guidelines for ACS enable to stratify patients undergoing PCI in categories with an incremental 1 year risk of MACE; however, their overall predictive ability for MACE is modest. Future studies should confirm the value of these criteria to identify patients benefiting from an extended treatment with a second antithrombotic agent.
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Affiliation(s)
- Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Davide Cao
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan 20072, Italy
| | - Samantha Sartori
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Ashutosh Sharma
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kenneth F Smith
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Birgit Vogel
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Karim Kamaleldin
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Anoop N Koshy
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Yihan Feng
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David Power
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Parasuram Krishnamoorthy
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Annapoorna Kini
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Samin K Sharma
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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16
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Watanabe H, Morimoto T, Natsuaki M, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Ono K, Kadota K, Suwa S, Morishima I, Yoshida R, Hata Y, Akao M, Yagi M, Suematsu N, Morino Y, Yokomatsu T, Takamisawa I, Noda T, Doi M, Okayama H, Nakamura Y, Hibi K, Sakamoto H, Noguchi T, Kimura T. Clopidogrel vs Aspirin Monotherapy Beyond 1 Year After Percutaneous Coronary Intervention. J Am Coll Cardiol 2024; 83:17-31. [PMID: 37879491 DOI: 10.1016/j.jacc.2023.10.013] [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: 10/07/2023] [Accepted: 10/13/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND It remains unclear whether clopidogrel is better suited than aspirin as the long-term antiplatelet monotherapy following dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). OBJECTIVES This study compared clopidogrel monotherapy following 1 month of DAPT (clopidogrel group) with aspirin monotherapy following 12 months of DAPT (aspirin group) after PCI for 5 years. METHODS STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy 2) is a multicenter, open-label, adjudicator-blinded, randomized clinical trial conducted in Japan. Patients who underwent PCI with cobalt-chromium everolimus-eluting stents were randomized in a 1-to-1 fashion either to clopidogrel or aspirin groups. The primary endpoint was a composite of cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis) or major bleeding (TIMI major or minor bleeding). RESULTS Among 3,005 study patients (age: 68.6 ± 10.7 years; women: 22.3%; acute coronary syndrome: 38.3%), 2,934 patients (97.6%) completed the 5-year follow-up (adherence to the study drugs at 395 days: 84.7% and 75.9%). The clopidogrel group compared with the aspirin group was noninferior but not superior for the primary endpoint (11.75% and 13.57%, respectively; HR: 0.85; 95% CI: 0.70-1.05; Pnoninferiority < 0.001; Psuperiority = 0.13), whereas it was superior for the cardiovascular outcomes (8.61% and 11.05%, respectively; HR: 0.77; 95% CI: 0.61-0.97; P = 0.03) and not superior for major bleeding (4.44% and 4.92%, respectively; HR: 0.89; 95% CI: 0.64-1.25; P = 0.51). By the 1-year landmark analysis, clopidogrel was numerically, but not significantly, superior to aspirin for cardiovascular events (6.79% and 8.68%, respectively; HR: 0.77; 95% CI: 0.59-1.01; P = 0.06) without difference in major bleeding (3.99% and 3.32%, respectively; HR: 1.23; 95% CI: 0.84-1.81; P = 0.31). CONCLUSIONS Clopidogrel might be an attractive alternative to aspirin with a borderline ischemic benefit beyond 1 year after PCI.
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Affiliation(s)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | | | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Ruka Yoshida
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Yoshiki Hata
- Department of Cardiology, Minamino Cardiovascular Hospital, Hachioji, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masahiro Yagi
- Department of Cardiology, Sendai Cardiovascular Center, Sendai, Japan
| | - Nobuhiro Suematsu
- Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Yahaba, Japan
| | | | - Itaru Takamisawa
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Toshiyuki Noda
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Masayuki Doi
- Department of Cardiology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Yuichi Nakamura
- Department of Cardiology, Hoshi General Hospital, Koriyama, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan.
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17
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Mostafa MR, Abdou C, Barssoum K, Jneid H. Aspirin vs P2Y 12 Inhibitors: A Few Questions Unanswered. J Am Coll Cardiol 2024; 83:e7. [PMID: 38171715 DOI: 10.1016/j.jacc.2023.09.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 01/05/2024]
Affiliation(s)
| | | | | | - Hani Jneid
- University of Texas Medical Branch, Galveston, Texas, USA
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18
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Lee K, Kang J, Park KW, Park TH, Kim BS, Lim SW, Cho YH, Jeon DW, Kim SH, Yang HM, Kang HJ, Han JK, Shin ES, Koo BK, Kim HS. Impact of Age on Antiplatelet Monotherapy in the Chronic Maintenance Period After Percutaneous Coronary Intervention: A Post Hoc Analysis From the HOST-EXAM Extended Study. Can J Cardiol 2024; 40:43-52. [PMID: 37742741 DOI: 10.1016/j.cjca.2023.09.021] [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: 07/10/2023] [Revised: 09/03/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUNDS The HOST-EXAM Extended study reported the benefit of clopidogrel monotherapy over aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI). This age-specific subgroup analysis of the study aimed to assess the impact of age on antiplatelet monotherapy after PCI. METHODS We analysed data from the per-protocol population (4717 patients) with a median follow-up of 5.8 years. The old age group comprised 2033 patients (43.1%), defined as those 65 years of age or older. The primary end point was the composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome (ACS), and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater. The secondary end points were thrombotic composite outcomes and any bleeding. RESULTS Age correlated with an elevated risk of adverse events, particularly from age 65. Clopidogrel monotherapy was associated with a reduction of the primary end point in both the old age group (19.4% vs 23.1%, hazard ratio [HR] 0.802, 95% confidence interval [CI] 0.664-0.968; P = 0.022) and the young age group (7.8% vs 11.7%, HR 0.646, 95% CI 0.506-0.825; P < 0.001), without significant interaction (interaction P = 0.167). These findings were consistent for the secondary composite thrombotic end point and any bleeding events (interaction P value of secondary thrombotic end point: 0.786; interaction P value of any bleeding end point: 0.565). Consistent results were observed in analyses with a 75-year age cutoff and in subgroup analyses by 10-year age intervals. CONCLUSIONS In patients requiring antiplatelet monotherapy after PCI, occurrence of both ischemic and bleeding events dramatically increased from age 65. The beneficial impact of clopidogrel over aspirin monotherapy was consistent regardless of age. CLINICAL TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02044250.
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Affiliation(s)
- Keehwan Lee
- Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul, Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul, Korea; Seoul National University College of Medicine, Seoul, Korea.
| | | | | | | | - Yoon Haeng Cho
- Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Dong Woon Jeon
- National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang-Hyun Kim
- Seoul National University College of Medicine, Seoul, Korea; Boramae Medical Centre, Seoul, Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul, Korea; Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul, Korea; Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul, Korea; Seoul National University College of Medicine, Seoul, Korea
| | | | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, Korea; Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul, Korea; Seoul National University College of Medicine, Seoul, Korea
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19
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Alkasab M, Bainey KR. Clopidogrel Monotherapy in Older Stable Ischemic Heart Disease Patients Receiving Percutaneous Coronary Intervention: A Paradigm Shift? Can J Cardiol 2024; 40:53-55. [PMID: 37924968 DOI: 10.1016/j.cjca.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/06/2023] Open
Affiliation(s)
- Mohammed Alkasab
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
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20
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Gragnano F, Capolongo A, Calabrò P. P2Y 12 Inhibitor or Aspirin Monotherapy in Patients with Coronary Artery Disease: is it Time for a Paradigm Shift? Curr Vasc Pharmacol 2024; 22:1-4. [PMID: 38018206 DOI: 10.2174/0115701611269735231106110250] [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: 07/23/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/30/2023]
Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy
- Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
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21
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Kovacevic M, Pompei G, Kunadian V. Tailoring antiplatelet therapy in older patients with coronary artery disease. Platelets 2023; 34:2285446. [PMID: 38050696 DOI: 10.1080/09537104.2023.2285446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
The older population represents a unique subset of patients due to a higher rate of comorbidities and risk factors, which can lead to a higher rate of ischemic and bleeding events. As a result, older adults are mainly underrepresented or excluded from randomized trials. Although the advancement in the percutaneous coronary intervention field with the development of new technologies, techniques, and potent antiplatelet therapy led to a reduction of ischemic risk, there is still a concern regarding bleeding hazards. Apart from the global utilization of less invasive trans-radial approach and proton pump inhibitors to reduce bleeding risk, proper tailoring of antiplatelet therapy in the older person is imperative. So far, several antiplatelet drugs have been introduced in different clinical scenarios, with dual antiplatelet therapy (combination of acetylsalicylic acid and P2Y12 inhibitor) recommended after percutaneous coronary intervention. The decision on the choice of antiplatelet drug and the DAPT duration is challenging and should be based on the relationship between ischemia and bleeding with the purpose of reducing ischemic events but not at the expense of increased bleeding complications. This is particularly important in the older population, where the evidence is obscure. The main objective of this review is to summarize the available evidence on contemporary antiplatelet therapy and different approaches of de-escalation strategies in older patients after percutaneous coronary intervention.
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Affiliation(s)
- Mila Kovacevic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Graziella Pompei
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK and
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK and
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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22
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Baber U, Spirito A, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff M, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Clinically Driven Revascularization in High-Risk Patients Treated With Ticagrelor Monotherapy After PCI: Insights from the Randomized TWILIGHT Trial. Am J Cardiol 2023; 208:16-24. [PMID: 37806185 DOI: 10.1016/j.amjcard.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
Repeat coronary revascularization is a common adverse event after successful percutaneous coronary intervention. This analysis aimed to assess the effects of ticagrelor monotherapy on repeat clinically driven revascularization (CDR). In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients after Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, high-risk patients were maintained on ticagrelor and randomly allocated to aspirin or placebo for 1 year. The primary end point of this analysis was CDR within 12 months after randomization. The key secondary end points were major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, myocardial infarction, stroke, or CDR, and net adverse clinical events (NACEs), including the individual components of MACCEs and clinically relevant bleeding. The analysis was performed in the per-protocol population. CDR occurred in 473 of 7,039 patients and was associated with a significantly higher risk of subsequent all-cause death, myocardial infarction, or stroke (adjusted hazard ratios [HRs] 2.92, 95% confidence interval [CI] 1.82 to 4.67). Ticagrelor monotherapy was associated with a similar 12-month risk of CDR (7.1% vs 6.6%; HR 1.09, 95% CI 0.90 to 1.30, p = 0.363) and MACCEs (8.9% vs 8.6%; HR 1.04, 95% CI 0.89 to 1.22, p = 0.619), and a lower risk of NACEs (12.2% vs 14.6%; HR 0.83 95% CI 0.73 to 0.94, p = 0.004) than ticagrelor plus aspirin. In conclusion, among high-risk patients who underwent percutaneous coronary intervention, ticagrelor monotherapy after 3 months of ticagrelor-based dual antiplatelet therapy was associated with a similar risk of CDR and MACCEs and a decrease of NACEs (TWILIGHT: NCT02270242).
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Affiliation(s)
- Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, New York; St. Francis Hospital, Roslyn, New York
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, Shenyang, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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23
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De Luca L, Gragnano F, Calabrò P, Huber K. Balancing Benefits and Risks of Oral Antiplatelet Strategies in patients With Coronary Artery Diseases: An Evolving Issue. Curr Probl Cardiol 2023; 48:102025. [PMID: 37553063 DOI: 10.1016/j.cpcardiol.2023.102025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Identifying the most appropriate antiplatelet therapy for each patient to prevent ischemic events while minimizing the risk of bleeding is an integral part of the short- and long-term management of patients with coronary artery disease (CAD). This review aims to summarize the available evidence on the contemporary use of P2Y12 inhibitors in CAD patients, focusing on strategies aimed at providing adequate ischemic protection while preventing bleeding risk through dual antiplatelet therapy (DAPT) modulation. Randomized trials and observational studies have been reviewed to determine the most appropriate antiplatelet treatment for CAD patients with different risk profiles. Both ischemic and bleeding events have a significant prognostic impact and should be carefully considered in clinical decision-making. Current guidelines recommend the use of third-generation PY2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel, as a part of DAPT, in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Newer P2Y12 inhibitors have a more rapid onset of action and less interindividual variability in platelet inhibition than clopidogrel but are associated with an increased risk of bleeding that may limit their benefit. Importantly, the anti-ischemic benefit of ticagrelor and prasugrel is mainly observed in the first weeks after ACS, whereas clopidogrel seems to provide the best balance between ischemic protection and bleeding as long-term maintenance therapy. These concepts support DAPT modulation after the acute phase, by de-escalating from full-dose to low-dose newer P2Y12 inhibitors, by switching to clopidogrel, or by early withdrawing aspirin to maximize both the efficacy and safety of antiplatelet therapy in patients with CAD.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, and Sigmund Freud University, Medical Faculty, Vienna, Austria
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24
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Carciotto G, Costa F, Garcia-Ruiz V, Galli M, Soraci E, Magliarditi A, Teresi L, Nasso E, Carerj S, Di Bella G, Micari A, De Luca G. Individualization of Duration of Dual Antiplatelet Therapy after Coronary Stenting: A Comprehensive, Evidence-Based Review. J Clin Med 2023; 12:7144. [PMID: 38002756 PMCID: PMC10672070 DOI: 10.3390/jcm12227144] [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: 10/11/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is the cornerstone of post-percutaneous coronary intervention treatment to prevent stent thrombosis and reduce the risk of adverse cardiovascular events. The selection of an optimal DAPT regimen, considering the interplay of various antiplatelet agents, patient profiles, and procedural characteristics, remains an evolving challenge. Traditionally, a standard duration of 12 months has been recommended for DAPT in most patients. While contemporary guidelines provide general frameworks, DAPT modulation with longer or shorter treatment courses followed by aspirin or P2Y12 inhibitor monotherapy are evolving towards an individualized strategy to optimize the balance between efficacy and safety. This review comprehensively examines the current landscape of DAPT strategies after coronary stenting, with a focus on emerging evidence for treatment individualization.
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Affiliation(s)
- Gabriele Carciotto
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Francesco Costa
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | | | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy;
| | - Emmanuele Soraci
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Alberto Magliarditi
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Lucio Teresi
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Enrica Nasso
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Antonio Micari
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | - Giuseppe De Luca
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
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25
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Oliva A, Cao D, Spirito A, Nicolas J, Pileggi B, Kamaleldin K, Vogel B, Mehran R. Personalized Approaches to Antiplatelet Treatment for Cardiovascular Diseases: An Umbrella Review. Pharmgenomics Pers Med 2023; 16:973-990. [PMID: 37941790 PMCID: PMC10629404 DOI: 10.2147/pgpm.s391400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023] Open
Abstract
Antiplatelet therapy is the cornerstone of antithrombotic prevention in patients with established atherosclerosis, since it has been proven to reduce coronary, cerebrovascular, and peripheral thrombotic events. However, the protective effect of antiplatelet agents is counterbalanced by an increase of bleeding events that impacts on patients' mortality and morbidity. Over the last years, great efforts have been made toward personalized antithrombotic strategies according to the individual bleeding and ischemic risk profile, aiming to maximizing the net clinical benefit. The development of risk scores, consensus definitions, and the new promising artificial intelligence tools, as well as the assessment of platelet responsiveness using platelet function and genetic testing, are now part of an integrated approach to tailored antithrombotic management. Moreover, novel strategies are available including dual antiplatelet therapy intensity and length modulation in patients undergoing myocardial revascularization, the use of P2Y12 inhibitor monotherapy for long-term secondary prevention, the implementation of parenteral antiplatelet agents in high-ischemic risk clinical settings, and combination of antiplatelet agents with low-dose factor Xa inhibitors (dual pathway inhibition) in patients suffering from polyvascular disease. This review summarizes the currently available evidence and provides an overview of the principal risk-stratification tools and antiplatelet strategies to inform treatment decisions in patients with cardiovascular disease.
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Affiliation(s)
- Angelo Oliva
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Cardio Center, Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Brunna Pileggi
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Cardiopneumonology, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Karim Kamaleldin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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Guedeney P, Farjat-Pasos JI, Asslo G, Roule V, Beygui F, Hermida A, Gabrion P, Leborgne L, Houde C, Huang F, Lattuca B, Leclercq F, Mesnier J, Abtan J, Rouanet S, Hammoudi N, Collet JP, Zeitouni M, Silvain J, Montalescot G, Rodés-Cabau J. Impact of the antiplatelet strategy following patent foramen ovale percutaneous closure. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:601-607. [PMID: 36963773 DOI: 10.1093/ehjcvp/pvad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/01/2023] [Accepted: 03/23/2023] [Indexed: 03/26/2023]
Abstract
AIMS Temporary dual antiplatelet therapy (DAPT) is recommended following patent foramen ovale (PFO) percutaneous closure although its benefit, compared to single antiplatelet therapy (SAPT), has not been demonstrated in this setting. We aimed at assessing outcomes following PFO closure according to the antiplatelet strategy at discharge. METHODS AND RESULTS The ambispective AIR-FORCE cohort included consecutive patients from seven centres in France and Canada undergoing PFO closure and discharged without anticoagulation. Patients treated in French and Canadian centres were mostly discharged with DAPT and SAPT, respectively. The primary endpoint was the composite of death, stroke, transient ischaemic attack, peripheral embolism, myocardial infarction, or BARC type ≥2 bleeding with up to 5 years of follow-up. The impact of the antiplatelet strategy on outcomes was evaluated with a marginal Cox model (cluster analyses per country) with inverse probability weighting according to propensity score. A total of 1532 patients (42.2% female, median age: 49 [40-57] years) were included from 2001 to 2022, of whom 599 (39.1%) were discharged with SAPT and 933 (60.9%) with DAPT, for ≤3 months in 894/923 (96.9%) cases. After a median follow-up of 2.4 [1.1-4.4] years, a total of 58 events were observed. In the weighted analysis, the rate of the primary endpoint up to 5 years was 7.8% in the SAPT strategy and 7.3% in the DAPT strategy (weighted hazard ratio 1.04, 95% confidence interval 0.59-1.83). CONCLUSION The antiplatelet strategy following PFO closure did not seem to impact clinical outcomes, thus challenging the current recommendations of temporary DAPT.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | | | - Gabriel Asslo
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Vincent Roule
- Service de Cardiologie, ACTION Study Group, Centre Hospitalier Universitaire (CHU) de Caen Normandie, Normandie Univ, INSERM UMRS 1237, GIP Cyceron, Caen, France
| | - Farzin Beygui
- Service de Cardiologie, ACTION Study Group, Centre Hospitalier Universitaire (CHU) de Caen Normandie, Normandie Univ, INSERM UMRS 1237, GIP Cyceron, Caen, France
| | - Alexis Hermida
- Cardiac Arrhythmia Service, Amiens-Picardie University Hospital, Amiens, France
| | - Paul Gabrion
- Cardiac Arrhythmia Service, Amiens-Picardie University Hospital, Amiens, France
| | - Laurent Leborgne
- Cardiac Arrhythmia Service, Amiens-Picardie University Hospital, Amiens, France
| | - Christine Houde
- Centre Hospitalier Universitaire de Québec, Quebec City, Quebec, Canada
| | - Florent Huang
- Service de Cardiologie, Hôpital Foch, Suresnes, France
| | - Benoit Lattuca
- ACTION Study Group, Cardiology Department, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Florence Leclercq
- Department of Cardiology, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Jules Mesnier
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
- FACT (French Alliance for Cardiovascular Clinical Trials), Université de Paris, INSERM U-1148, Hôpital Bichat (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Jérémie Abtan
- FACT (French Alliance for Cardiovascular Clinical Trials), Université de Paris, INSERM U-1148, Hôpital Bichat (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Stéphanie Rouanet
- Statistician Unit, StatEthic, ACTION Study Group, Levallois-Perret, France
| | - Nadjib Hammoudi
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Michel Zeitouni
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
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Ortega-Paz L, Sabaté M, Angiolillo DJ. Long-Term Clopidogrel Monotherapy After Percutaneous Coronary Intervention: Will the Pupil Surpass the Master? J Am Coll Cardiol 2023; 82:1579-1582. [PMID: 37821167 DOI: 10.1016/j.jacc.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
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28
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Yang S, Kang J, Park KW, Hur SH, Lee NH, Hwang D, Yang HM, Ahn HS, Cha KS, Jo SH, Ryu JK, Suh IW, Choi HH, Woo SI, Han JK, Shin ES, Koo BK, Kim HS. Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic, and Bleeding Risks. J Am Coll Cardiol 2023; 82:1565-1578. [PMID: 37821166 DOI: 10.1016/j.jacc.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Clopidogrel was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI). OBJECTIVES The purpose of this study was to evaluate the benefits of clopidogrel across high-risk subgroups METHODS: This was a post hoc analysis of the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy) trial that randomly assigned patients who were event free for 6 to 18 months post-PCI on dual antiplatelet therapy (DAPT) to clopidogrel or aspirin monotherapy. Two clinical risk scores were used for risk stratification: the DAPT score and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) (the sum of age ≥75 years, diabetes, hypertension, current smoking, peripheral artery disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction). The primary composite endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission because of acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type ≥3) at 2 years after randomization. RESULTS Among 5,403 patients, clopidogrel monotherapy showed a lower rate of the primary composite endpoint than aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90). The benefit of clopidogrel over aspirin was consistent regardless of TRS 2°P (high TRS 2°P [≥3] group: HR: 0.65 [95% CI: 0.44-0.96]; and low TRS 2°P [<3] group: HR: 0.77 [95% CI: 0.60-0.99]) (P for interaction = 0.454) and regardless of DAPT score (high DAPT score [≥2] group: HR: 0.68 [95% CI: 0.46-1.00]; and low DAPT score [<2] group: HR: 0.75 [95% CI: 0.59-0.96]) (P for interaction = 0.662). The association was similar for the individual outcomes. CONCLUSIONS The beneficial effect of clopidogrel over aspirin monotherapy was consistent regardless of clinical risk or relative ischemic and bleeding risks compared with aspirin monotherapy. (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis- EXtended Antiplatelet Monotherapy [HOST-EXAM]; NCT02044250).
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Affiliation(s)
- Seokhun Yang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Seung-Ho Hur
- Keimyung University Dongsan Hospital, Daegu, Republic of Korea.
| | - Nam Ho Lee
- Kangnam Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Suk Ahn
- Uijeongbu St Mary's Hospital, Uijeongbu, Republic of Korea
| | - Kwang Soo Cha
- Pusan National University Hospital, Busan, Republic of Korea
| | - Sang-Ho Jo
- Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jae Kean Ryu
- Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Il-Woo Suh
- Anyang SAM Medical Center, Anyang, Republic of Korea
| | - Hyun-Hee Choi
- Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Seong-Ill Woo
- Inha University Hospital, Inha University, Incheon, Republic of Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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29
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Zhang J, Chen Z, Cai Y, Li C, He Y. Comparison of Different Chronic Maintenance Antithrombotic Strategies in Patients with Coronary Artery Disease: A Systematic Review and Network Meta-Analysis. Cardiovasc Ther 2023; 2023:5446271. [PMID: 37636560 PMCID: PMC10449594 DOI: 10.1155/2023/5446271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/09/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Background Optimal antithrombotic therapy during the chronic maintenance period in patients with coronary artery disease (CAD) is unknown. We compared five kinds of mainstream chronic maintenance antithrombotic strategies at least one year after the acute phase: aspirin alone, clopidogrel alone, ticagrelor alone, continued dual antiplatelet therapy (DAPT) for a period of time, and maintenance with aspirin combined with a low-dose anticoagulant such as rivaroxaban. Methods Ten randomized, controlled trials were selected using PubMed, Ovid MEDLINE, Embase, and Cochrane library through February 2023. The primary outcome was main adverse cardiac events (MACEs), and secondary outcomes include net adverse clinical events (NACEs), cardiac death, all-cause death, ischemic stroke, stent thrombosis, total bleeding, and major bleeding. A network meta-analysis was conducted with a random-effects model. Data extraction was performed by three independent reviewers. Results Our search identified ten eligible randomized controlled trials enrolling a total of 82,084 patients comparing different chronic maintenance antithrombotic strategies. As for the primary endpoint, there was no statistical difference in MACE outcomes between any two of the five methods. As for the secondary endpoint, there was no statistical difference in NACE, major bleeding, all-cause death, cardiac death, and stent thrombosis between any two methods. The aspirin plus low-dose rivaroxaban group had a lower incidence of ischemic stroke compared to the aspirin group (OR = 0.49, 95% CrI 0.26-0.91). And the prolonged DAPT group had a higher total bleeding rate compared to aspirin group (OR = 2.4, 95% CrI 1.1-5.9). Conclusions In terms of MACE, NACE, all-cause death, cardiac death, stent thrombosis, and major bleeding, there were no significant differences between using aspirin alone, clopidogrel alone, and ticagrelor alone; extending DAPT duration; and using aspirin combined with low-dose rivaroxaban for chronic maintenance antithrombotic regimens. However, choosing aspirin combined with low-dose rivaroxaban can reduce the incidence of ischemic stroke, and prolonged DAPT may have a higher rate of total bleeding. However, it is important to note that this study is based on indirect comparisons, and there is currently a lack of direct evidence comparing various maintenance antiplatelet therapy regimens. Further high-quality studies are needed to address this gap and provide more conclusive evidence on the comparative effectiveness of different maintenance antiplatelet strategies.
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Affiliation(s)
- Junyan Zhang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yujia Cai
- Chinese Evidence-Based Medicine Center and MAGIC-China Center, West China Hospital, Sichuan University, Chengdu, China
| | - Chen Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yong He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
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30
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Yu Y, Pan D, Bai R, Luo J, Tan Y, Duan W, Shi D. P2y 12 inhibitor monotherapy after 1-3 months dual antiplatelet therapy in patients with coronary artery disease and chronic kidney disease undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197161. [PMID: 37485257 PMCID: PMC10357506 DOI: 10.3389/fcvm.2023.1197161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction In patients with coronary artery disease (CAD) and chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), whether short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitors confers benefits compared with standard DAPT remains unclear. This study aimed to assess the efficacy and safety of 1-3 months of DAPT followed by P2Y12 monotherapy in patients with CAD and CKD undergoing PCI. Methods PubMed, Embase, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) comparing the P2Y12 inhibitor monotherapy after a 1-3 months DAPT vs. DAPT in patients with CAD and CKD after PCI. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, target-vessel revascularization, and stroke. The safety outcome was the major bleeding events, defined as a composite of TIMI major bleeding or Bleeding Academic Research and Consortium (BARC) type 2, 3, or 5 bleeding. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a fixed- or random-effects model depending on the heterogeneity among studies. Results Four RCTs including 20,468 patients (2,833 patients with CKD and 17,635 without CKD) comparing P2Y12 inhibitor monotherapy with DAPT were included in our meta-analysis. Patients with CAD and CKD had higher risk of ischemic and bleeding events. P2Y12 inhibitor monotherapy after 1-3 months of DAPT significantly reduced the risk of major bleeding compared to DAPT in CKD patients (RR: 0.69, 95% CI: 0.51-0.95, P = 0.02) and non-CKD patients (RR: 0.66, 95% CI: 0.49-0.89, P = 0.01). No significant difference regarding MACEs between P2Y12 inhibitor monotherapy and DAPT was found in CKD patients (RR: 0.88, 95% CI: 0.59-1.31, P = 0.53) and non-CKD (RR: 0.91, 95% CI: 0.79-1.04, P = 0.17). Conclusion P2Y12 inhibitor monotherapy after 1-3 months of DAPT was an effective strategy for lowering major bleeding complications without increasing the risk of cardiovascular events in patients with CAD and CKD undergoing PCI as compared with DAPT. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022355228.
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Affiliation(s)
- Yanqiao Yu
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruina Bai
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinwen Luo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Tan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenhui Duan
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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31
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Arockiam S, Staniforth B, Kepreotis S, Maznyczka A, Bulluck H. A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice. Int J Mol Sci 2023; 24:11132. [PMID: 37446310 DOI: 10.3390/ijms241311132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient's thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.
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Affiliation(s)
- Sacchin Arockiam
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Brittany Staniforth
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Sacha Kepreotis
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Annette Maznyczka
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
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32
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Kang J, Chung J, Park KW, Lee H, Hwang D, Yang HM, Han JK, Shin ES, Koo BK, Kim HS. Clopidogrel vs Aspirin in the Chronic Maintenance Period for Patients With Acute Coronary Syndrome. JACC Cardiovasc Interv 2023; 16:1553-1555. [PMID: 37380245 DOI: 10.1016/j.jcin.2023.03.004] [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: 02/17/2023] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 06/30/2023]
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33
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Rhee TM, Bae JW, Park KW, Rha SW, Kang J, Lee H, Yang HM, Kwak SH, Chae IH, Shin WY, Kim DK, Oh JH, Jeong MH, Kim YH, Lee NH, Hur SH, Yoon J, Han JK, Shin ES, Koo BK, Kim HS. Aspirin vs Clopidogrel for Long-term Maintenance After Coronary Stenting in Patients With Diabetes: A Post Hoc Analysis of the HOST-EXAM Trial. JAMA Cardiol 2023; 8:535-544. [PMID: 37043192 PMCID: PMC10099092 DOI: 10.1001/jamacardio.2023.0592] [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: 09/17/2022] [Accepted: 02/20/2023] [Indexed: 04/13/2023]
Abstract
Importance Selecting the optimal antiplatelet agent in patients who have received percutaneous coronary intervention is especially important in those with diabetes due to the heightened risk of ischemic events in this population. Studies on the efficacy and safety of clopidogrel vs aspirin for long-term maintenance after percutaneous coronary intervention in patients with diabetes are lacking. Objective To investigate cardiovascular outcomes with clopidogrel vs aspirin in patients with and without diabetes. Design, Setting, and Participants This was a post hoc analysis of the HOST-EXAM randomized clinical trial, an investigator-initiated, prospective, randomized, open-label, multicenter trial performed at 37 centers in Korea. Patients who received dual antiplatelet therapy without clinical events for 6 to 18 months after percutaneous coronary intervention with drug-eluting stents were enrolled from March 2014 to May 2018 with follow-up at 6, 12, 18, and 24 months. All 5438 patients in the original trial were included in this analysis, which was conducted from June to October 2021. Interventions and Exposures Enrolled patients were randomized 1:1 to clopidogrel or aspirin monotherapy. Subgroup analyses were performed by the presence of diabetes. Main Outcomes and Measures The main outcome was primary composite end point of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type 3 or 5) at 24-month follow-up. Results Of 5438 patients (mean [SD] age, 63.5 [10.7] years; 1384 [25.5%] female), 1860 (34.2%) had diabetes (925 in the clopidogrel arm and 935 in the aspirin arm), and 5338 (98.2%) completed follow-up. The rate of the primary composite end point was significantly lower in the clopidogrel group compared to the aspirin group in patients with diabetes (6.3% vs 9.2%; hazard ratio [HR], 0.69; 95% CI, 0.49-0.96; P = .03; absolute risk difference [ARD], 2.7%; number needed to treat [NNT], 37) and without diabetes (5.3% vs 7.0%; HR, 0.76; 95% CI, 0.58-1.00; P = .046; ARD, 1.6%, NNT, 63; P for interaction = .65). The presence of diabetes was not associated with a difference in benefit observed with clopidogrel monotherapy over aspirin for the thrombotic composite end point (HR, 0.68; 95% CI, 0.45-1.04 for patients with diabetes vs HR, 0.68; 95% CI, 0.49-0.93 for those without; P for interaction = .99) and any bleeding with Bleeding Academic Research Consortium 2, 3, or 5 (HR, 0.65; 95% CI, 0.39-1.09 for patients with diabetes vs HR, 0.74; 95% CI, 0.48-1.13 for those without; P for interaction = .71). Conclusion and Relevance In this study, clopidogrel monotherapy was associated with a lower rate of the primary composite end point compared to aspirin monotherapy as long-term maintenance therapy after dual antiplatelet therapy for coronary stenting in both patients with and without diabetes. Clopidogrel might thus be considered rather than aspirin in patients who have undergone coronary stenting and successfully completed dual antiplatelet therapy, regardless of diabetes status. Trial Registration ClinicalTrials.gov Identifier: NCT02044250.
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Affiliation(s)
- Tae-Min Rhee
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Jang-Whan Bae
- Chungbuk National University College of Medicine, Cheongju, Korea
| | - Kyung Woo Park
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | | | - Jeehoon Kang
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Heesun Lee
- Seoul National University Healthcare System Gangnam Center, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Mo Yang
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Soo-Heon Kwak
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - In-Ho Chae
- Seoul National University Bundang Hospital, Seongnam, Korea
| | - Won-Yong Shin
- Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | | | - Ju Hyeon Oh
- Samsung Changwon Hospital, Sungkyunkwan University, Changwon, Korea
| | | | - Yong Hoon Kim
- Kangwon National University, School of Medicine, Chuncheon, Korea
| | - Nam Ho Lee
- Kangnam Sacred Heart Hospital, Hallym University, Seoul, Korea
| | - Seung-Ho Hur
- Keimyung University Dongsan Hospital, Daegu, Korea
| | - Junghan Yoon
- Yonsei University Wonju Severance Christian Hospital, Wonju, Korea
| | - Jung-Kyu Han
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | | | - Bon-Kwon Koo
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
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Otieno B, Ibecheozor C, Williams MS. What Is the Optimal Duration of Antiplatelet Therapy for Patients with Coronary Heart Disease? Curr Atheroscler Rep 2023:10.1007/s11883-023-01108-z. [PMID: 37178416 DOI: 10.1007/s11883-023-01108-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE OF REVIEW Optimal duration of antiplatelet therapy continues to attract extensive debates and has been progressively adjusted in the setting of advancements in stent design and assessment of patient clinical characteristics. Given the ever-changing landscape of antiplatelet therapy and the multitude of clinical trials that have examined this duration, there are varying scenarios for optimal duration based on patient presentation and risk profile. This review highlights the current concepts and recommendations regarding duration of antiplatelet therapy in coronary heart disease. RECENT FINDINGS In particular, we review the current data on the use of dual antiplatelet therapy in the different clinical scenarios. Relatively longer dual antiplatelet therapy is perhaps limited to patients with higher risk for cardiovascular events and/or high-risk lesions and shorter durations of dual antiplatelet therapy have been shown to reduce bleeding complications at the same time as stabilization of ischemic endpoints. More recent trials have demonstrated the safety of shorter durations of dual antiplatelet therapy in appropriate patients with coronary heart disease.
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Affiliation(s)
- Beryl Otieno
- Greater Baltimore Medical Center, Towson, MD, USA
| | | | - Marlene S Williams
- Division of Cardiology, The Johns Hopkins University School of Medicine, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.
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35
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Carlin S, Eikelboom J. Are P2Y12 inhibitors superior to aspirin for long-term secondary prevention of cardiovascular disease? Expert Rev Cardiovasc Ther 2023; 21:305-309. [PMID: 37010071 DOI: 10.1080/14779072.2023.2199155] [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: 02/22/2023] [Accepted: 03/31/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Stephanie Carlin
- Thrombosis Service, Hamilton General Hospital, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - John Eikelboom
- Thrombosis Service, Hamilton General Hospital, Hamilton, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
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36
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Verheugt FWA. MASTER-DAPT: A Further Step Toward Long-Term P2Y 12 Blocker Monotherapy After PCI. JACC Cardiovasc Interv 2023; 16:813-815. [PMID: 37045501 DOI: 10.1016/j.jcin.2023.02.016] [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: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands.
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37
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Rodriguez AE, Fernandez-Pereira C, Mieres JR, Rodriguez-Granillo AM. High Non-Cardiac Death Incidence Should Be a Limitation of Drug-Eluting Stents Implantation? Insights from Recent Randomized Data. Diagnostics (Basel) 2023; 13:diagnostics13071321. [PMID: 37046540 PMCID: PMC10093159 DOI: 10.3390/diagnostics13071321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/16/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Despite the introduction of drug-eluting stents (DES) significantly improved the efficacy and safety of percutaneous coronary interventions (PCI), particularly in a high-risk group of patients, the gap between PCI with his competitor’s coronary artery bypass surgery (CABG) and/or optimal medical treatment alone was not reduced. In this revision, we highlighted the fact that in recent years landmark randomized studies reported at mid and long-term follow-ups a high incidence of non-cardiac death, cancer incidence, or both in the DES group of patients. The overall incidence of non-cardiac death was significantly higher in the DES vs. the comparator arm: 5.5% and 3.8%, respectively, p = 0.000018, and non-cardiac death appears to be more divergent between DES vs. the comparator at the extended follow-up to expenses of the last one. One of these trials reported five times greater cancer incidence in the DES arm at late follow-up, 5% vs. 0.7% p < 0.0018. We review the potential reason for these unexpected findings, although we can discard that DES biology could be involved in it. Until all these issues are resolved, we propose that DES implantation should be tailored accorded patient age, life expectancy, and lesion complexity.
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Affiliation(s)
- Alfredo E. Rodriguez
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
| | - Carlos Fernandez-Pereira
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
| | - Juan Ramon Mieres
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
| | - Alfredo Matias Rodriguez-Granillo
- Cardiac Unit, Otamendi Hospital, Post Graduate Buenos Aires School of Medicine, Cardiovascular Research Center (CECI), 868 Buenos Aires, Argentina
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38
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Spartalis M, Siasos G. Challenging the "Divinity" of Aspirin Monotherapy for Secondary Prevention of Cardiovascular Disease. JACC. ASIA 2023; 3:208-210. [PMID: 37181392 PMCID: PMC10167494 DOI: 10.1016/j.jacasi.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Michael Spartalis
- Third Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Sotiria Thoracic Diseases General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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39
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De Servi S, Landi A, Savonitto S, Morici N, De Luca L, Montalto C, Crimi G, De Rosa R, De Luca G. Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field. J Clin Med 2023; 12:2082. [PMID: 36902869 PMCID: PMC10003933 DOI: 10.3390/jcm12052082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/23/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, 27100 Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland
| | | | - Nuccia Morici
- IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy
| | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, 00152 Roma, Italy
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
- Clinical and Interventional Cardiology, Istituto Clinico Sant’Ambrogio, Gruppo San Donato, 20122 Milan, Italy
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS, Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Roberta De Rosa
- University Hospital San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
- Goethe University Hospital Frankfurt, 60528 Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98039 Messina, Italy
- Division of Cardiology, Nuovo Galeazzi-Sant’Ambrogio Hospital, 20161 Milan, Italy
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40
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Capodanno D, Angiolillo DJ. Long-Term P2Y 12 Inhibitor or Aspirin as Single Antiplatelet Therapy in Patients With Previous Percutaneous Coronary Intervention. Circulation 2023; 147:118-121. [PMID: 36622905 DOI: 10.1161/circulationaha.122.063004] [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] [Indexed: 01/11/2023]
Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico Gaspare Rodolico-San Marco, University of Catania, Italy (D.C.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
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41
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Manfredi R, Verdoia M, Compagnucci P, Barbarossa A, Stronati G, Casella M, Dello Russo A, Guerra F, Ciliberti G. Angina in 2022: Current Perspectives. J Clin Med 2022; 11:jcm11236891. [PMID: 36498466 PMCID: PMC9737178 DOI: 10.3390/jcm11236891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
Angina is the main symptom of ischemic heart disease; mirroring a mismatch between oxygen supply and demand. Epicardial coronary stenoses are only responsible for nearly half of the patients presenting with angina; whereas in several cases; symptoms may underlie coronary vasomotor disorders; such as microvascular dysfunction or epicardial spasm. Various medications have been proven to improve the prognosis and quality of life; representing the treatment of choice in stable angina and leaving revascularization only in particular coronary anatomies or poorly controlled symptoms despite optimal medical therapy. Antianginal medications aim to reduce the oxygen supply-demand mismatch and are generally effective in improving symptoms; quality of life; effort tolerance and time to ischemia onset and may improve prognosis in selected populations. Since antianginal medications have different mechanisms of action and side effects; their use should be tailored according to patient history and potential drug-drug interactions. Angina with non-obstructed coronary arteries patients should be phenotyped with invasive assessment and treated accordingly. Patients with refractory angina represent a higher-risk population in which some therapeutic options are available to reduce symptoms and improve quality of life; but robust data from large randomized controlled trials are still lacking.
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Affiliation(s)
- Roberto Manfredi
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Monica Verdoia
- Division of Cardiology Ospedale degli Infermi, ASL, 13875 Biella, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Giulia Stronati
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
- Correspondence:
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