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Qamar U, Naeem F, Maqsood MT, Khan MZ, Imtiaz Z, Saeed F, Gupta N, Brohi FZ, Mkpozi C, Sattar Y. Efficacy and safety of ticagrelor monotherapy following a brief DAPT vs. prolonged 12-month DAPT in ACS patients post-PCI: a meta-analysis of RCTs. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03747-w. [PMID: 39264445 DOI: 10.1007/s00228-024-03747-w] [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: 05/19/2024] [Accepted: 08/21/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND As per current guidelines, acute coronary syndrome (ACS) patients who undergo percutaneous coronary intervention (PCI) should be started on dual antiplatelet therapy (DAPT) for a period of 12 months. OBJECTIVE To assess the efficacy and safety of brief DAPT (up to 3 months) succeeded by ticagrelor monotherapy compared with a 12-month DAPT in ACS patients following PCI. METHODS We systematically searched Cochrane, Embase, and PubMed to find relevant randomized clinical trials. Examined outcomes included the incidence of major adverse cerebrovascular and cardiovascular events (MACCE), bleeding events, and the composite incidence of net adverse clinical events (NACE). RESULTS Our primary analysis included 21,927 ACS patients from six RCTs. Our pooled results indicate that following PCI in individuals with ACS, brief DAPT followed by ticagrelor did not increase the risk of MACCE (OR 0.92, 95% CI 0.79-1.07) but significantly reduced the risk of minor or major bleeding (OR 0.52, 95% CI 0.44-0.62) and NACE (OR 0.71, 95% CI 0.59-0.86) compared with a long-term DAPT within a follow-up of 12 months. CONCLUSION Brief DAPT followed by ticagrelor monotherapy is superior to a 12-month DAPT in offering a net clinical advantage in ACS patients following PCI.
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Affiliation(s)
- Usama Qamar
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Farhan Naeem
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | | | - Maleeka Zamurad Khan
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Zeeshan Imtiaz
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Fatima Saeed
- Department of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Neelesh Gupta
- Department of Cardiology, Kirk Kerkorian School of Medicine at the, University of Nevada, Las Vegas, USA
| | | | - Celestine Mkpozi
- Department of Internal Medicine and Department of Cardiology, West Virginia University, 1 Medical Ctr Dr., Morgantown, WV, 26506, USA
| | - Yasar Sattar
- Department of Internal Medicine and Department of Cardiology, West Virginia University, 1 Medical Ctr Dr., Morgantown, WV, 26506, USA.
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Improta R, Di Pietro G, Piccialuti A, De Filippo O, Birtolo I, Severino P, Tocci M, Saade W, Cammertoni F, Vizza D, Sardella G, D'Ascenzo F, Stefanini G, Mancone M. Invasive and conservative management of elderly patients presenting with acute coronary syndrome: A meta-analysis of randomized controlled trials and adjusted observational studies. Int J Cardiol 2024; 417:132523. [PMID: 39255918 DOI: 10.1016/j.ijcard.2024.132523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 08/12/2024] [Accepted: 09/04/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Elderly patients are often under-represented in studies about coronary revascularization in acute coronary syndromes (ACS) and undertreated in clinical practice. We sought to evaluate differences in outcomes between an initial invasive or conservative strategy in this subset of patients, METHODS: The analysis was performed following PRISMA guidelines. Randomized controlled trials (RCTs) and adjusted observational studies comparing an invasive and conservative strategy in old patients with ACS were systematically identified. Random or fixed effect model was used accordingly to heterogeneity testing results. Short-term mortality was the primary outcome. 30-day and longer-term re-infarction, MACE and all-cause mortality were secondary endpoints. Sensitivity analysis including RCTs only were performed for the primary endpoint and 1 year mortality and another analysis, stratifying NSTEMI and STEMI studies, was performed for short-term mortality. RESULTS Invasive management was associated with lower short and long-term mortality (30 days OR 0.64, 95 % CI 0.54-0.76, p < 0.001; 1 year HR 0.60, 95 % CI 0.52-0.78, p < 0.001; Long-term HR 0.62, 95 % CI 0.55-0.71, p < 0.001) compared to a conservative strategy. In the short-term follow-up, the benefit was preserved when differentiating for NSTEMI or STEMI studies but not when considering only RCTs. Major bleedings were more frequent in the invasive group (30 days OR 1.61, 95 % CI 1.39-1.87, p < 0.001). The mean difference in length of stay was not significantly different between the two strategies (mean difference in days 0.14, 95 % CI -0.79 to 1.06, p = 0.77). CONCLUSION An initial invasive strategy might lead to reduced short and long-term mortality in elderly patients presenting with acute coronary syndrome but it is associated with increased bleeding events rate. No difference in hospital stay length was observed. Results were mainly driven by non-randomized studies.
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Affiliation(s)
- Riccardo Improta
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Gianluca Di Pietro
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Alice Piccialuti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Ovidio De Filippo
- Department of Medical Sciences, University of Turin, Division of Cardiology, Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Turin, Italy
| | - Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Marco Tocci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Wael Saade
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Gennaro Sardella
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Fabrizio D'Ascenzo
- Department of Medical Sciences, University of Turin, Division of Cardiology, Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Turin, Italy
| | - Giulio Stefanini
- Operative Unit of Clinical and Interventional Cardiology and Intensive Coronary Care Unit, Humanitas Research Hospital, Milan, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy; Department of Medical Sciences, University of Turin, Division of Cardiology, Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Turin, Italy.
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3
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Valgimigli M, Hong SJ, Gragnano F, Chalkou K, Franzone A, da Costa BR, Baber U, Kim BK, Jang Y, Chen SL, Stone GW, Hahn JY, Windecker S, Gibson MC, Song YB, Ge Z, Vranckx P, Mehta S, Gwon HC, Lopes RD, Dangas GD, McFadden EP, Angiolillo DJ, Leonardi S, Heg D, Calabrò P, Jüni P, Mehran R, Hong MK. De-escalation to ticagrelor monotherapy versus 12 months of dual antiplatelet therapy in patients with and without acute coronary syndromes: a systematic review and individual patient-level meta-analysis of randomised trials. Lancet 2024; 404:937-948. [PMID: 39226909 DOI: 10.1016/s0140-6736(24)01616-7] [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: 06/19/2024] [Revised: 07/31/2024] [Accepted: 08/02/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) for 12 months is the standard of care after coronary stenting in patients with acute coronary syndrome (ACS). The aim of this individual patient-level meta-analysis was to summarise the evidence comparing DAPT de-escalation to ticagrelor monotherapy versus continuing DAPT for 12 months after coronary drug-eluting stent implantation. METHODS A systematic review and individual patient data (IPD)-level meta-analysis of randomised trials with centrally adjudicated endpoints was performed to evaluate the comparative efficacy and safety of ticagrelor monotherapy (90 mg twice a day) after short-term DAPT (from 2 weeks to 3 months) versus 12-month DAPT in patients undergoing percutaneous coronary intervention with a coronary drug-eluting stent. Randomised trials comparing P2Y12 inhibitor monotherapy with DAPT after coronary revascularisation were searched in Ovid MEDLINE, Embase, and two websites (www.tctmd.com and www.escardio.org) from database inception up to May 20, 2024. Trials that included patients with an indication for long-term oral anticoagulants were excluded. The risk of bias was assessed using the revised Cochrane risk-of-bias tool. The principal investigators of the eligible trials provided IPD by means of an anonymised electronic dataset. The three ranked coprimary endpoints were major adverse cardiovascular or cerebrovascular events (MACCE; a composite of all-cause death, myocardial infarction, or stroke) tested for non-inferiority in the per-protocol population; and Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding and all-cause death tested for superiority in the intention-to-treat population. All outcomes are reported as Kaplan-Meier estimates. The non-inferiority was tested using a one-sided α of 0·025 with the prespecified non-inferiority margin of 1·15 (hazard ratio [HR] scale), followed by the ranked superiority testing at a two-sided α of 0·05. This study is registered with PROSPERO (CRD42024506083). FINDINGS A total of 8361 unique citations were screened, of which 610 records were considered potentially eligible during the screening of titles and abstracts. Of these, six trials that randomly assigned patients to ticagrelor monotherapy or DAPT were identified. De-escalation took place a median of 78 days (IQR 31-92) after intervention, with a median duration of treatment of 334 days (329-365). Among 23 256 patients in the per-protocol population, MACCE occurred in 297 (Kaplan-Meier estimate 2·8%) with ticagrelor monotherapy and 332 (Kaplan-Meier estimate 3·2%) with DAPT (HR 0·91 [95% CI 0·78-1·07]; p=0·0039 for non-inferiority; τ2<0·0001). Among 24 407 patients in the intention-to-treat population, the risks of BARC 3 or 5 bleeding (Kaplan-Meier estimate 0·9% vs 2·1%; HR 0·43 [95% CI 0·34-0·54]; p<0·0001 for superiority; τ2=0·079) and all-cause death (Kaplan-Meier estimate 0·9% vs 1·2%; 0·76 [0·59-0·98]; p=0·034 for superiority; τ2<0·0001) were lower with ticagrelor monotherapy. Trial sequential analysis showed strong evidence of non-inferiority for MACCE and superiority for bleeding among the overall and ACS populations (the z-curve crossed the monitoring boundaries or the required information size without crossing the futility boundaries or approaching the null). The treatment effects were heterogeneous by sex for MACCE (p interaction=0·041) and all-cause death (p interaction=0·050), indicating a possible benefit in women with ticagrelor monotherapy, and by clinical presentation for bleeding (p interaction=0·022), indicating a benefit in ACS with ticagrelor monotherapy. INTERPRETATION Our study found robust evidence that, compared with 12 months of DAPT, de-escalation to ticagrelor monotherapy does not increase ischaemic risk and reduces the risk of major bleeding, especially in patients with ACS. Ticagrelor monotherapy might also be associated with a mortality benefit, particularly among women, which warrants further investigation. FUNDING Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale.
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Affiliation(s)
- Marco Valgimigli
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Sung-Jin Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno R da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael C Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Zhen Ge
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Sergio Leonardi
- Department of Cardiology, University of Pavia and Fondazione IRCCS Policlinico S Matteo, Pavia, Italy
| | - Dik Heg
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
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4
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Stefanini GG, Oliva A. Is this the conclusive evidence for ticagrelor monotherapy in acute coronary syndromes? Lancet 2024; 404:908-909. [PMID: 39226908 DOI: 10.1016/s0140-6736(24)01678-7] [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: 08/04/2024] [Accepted: 08/12/2024] [Indexed: 09/05/2024]
Affiliation(s)
- Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan 20090, Italy; Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.
| | - Angelo Oliva
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan 20090, Italy; Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
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5
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van den Broek WWA, Ten Berg JM. The puzzle of antiplatelet therapy in ACS: ticagrelor monotherapy is another missing piece. Eur Heart J 2024; 45:3057-3059. [PMID: 39056261 DOI: 10.1093/eurheartj/ehae440] [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: 07/28/2024] Open
Affiliation(s)
- Wout W A van den Broek
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
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6
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Cohen M, Jones C. Patient and Physician Perspectives on the Benefits and Risks of Antiplatelet Therapy for Acute Coronary Syndrome. Cardiol Ther 2024; 13:631-643. [PMID: 38907182 PMCID: PMC11333664 DOI: 10.1007/s40119-024-00372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
This article is co-authored by a patient with acute coronary syndrome (ACS) who is receiving long-term antiplatelet therapy in the USA and a cardiologist who routinely treats patients with ACS. The patient describes his experience from diagnosis to the present day and discusses his concerns regarding treatment and management of the condition, including the balance between the benefits and risks of antiplatelet therapy. The patient also describes his work as an advocate for cardiac health. The physician perspective on treating and managing patients with ACS is provided by a cardiologist based in the USA who is and was not involved in this patient's care. The physician reviews the benefits and risks of antiplatelet therapies for the treatment of patients with ACS and discusses his own clinical experience of managing these patients, including how issues such as treatment adherence, as well as the potential inertia to prescribing certain medications that may be seen among physicians, could be overcome.
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Affiliation(s)
- Marc Cohen
- Newark Beth Israel Medical Center, 201 Lyons Avenue at Osborne Terrace, Newark, NJ, USA.
- Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ, USA.
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7
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Lee YJ, Shin S, Kwon SW, Suh Y, Yun KH, Kang TS, Lee JW, Cho DK, Park JK, Bae JW, Kang WC, Kim S, Lee SJ, Hong SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK. Ticagrelor monotherapy for acute coronary syndrome: an individual patient data meta-analysis of TICO and T-PASS trials. Eur Heart J 2024; 45:3045-3056. [PMID: 38750627 DOI: 10.1093/eurheartj/ehae249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/22/2024] [Accepted: 04/08/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND AND AIMS In patients with acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 inhibitor is recommended for 12 months after drug-eluting stent (DES) implantation. Monotherapy with a potent P2Y12 inhibitor after short-term DAPT is an attractive option to better balance the risks of ischaemia and bleeding. Therefore, this study evaluated the efficacy and safety of ticagrelor monotherapy after short-term DAPT, especially in patients with ACS. METHODS Electronic databases were searched from inception to 11 November 2023, and for the primary analysis, individual patient data were pooled from the relevant randomized clinical trials comparing ticagrelor monotherapy after short-term (≤3 months) DAPT with ticagrelor-based 12-month DAPT, exclusively in ACS patients undergoing DES implantation. The co-primary endpoints were ischaemic endpoint (composite of all-cause death, myocardial infarction, or stroke) and bleeding endpoint [Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding] at 1 year. RESULTS Individual patient data from two randomized clinical trials including 5906 ACS patients were analysed. At 1 year, the primary ischaemic endpoint did not differ between the ticagrelor monotherapy and ticagrelor-based DAPT groups [1.9% vs. 2.5%; adjusted hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.56-1.13; P = .194]. The incidence of the primary bleeding endpoint was lower in the ticagrelor monotherapy group (2.4% vs. 4.5%; adjusted HR 0.54; 95% CI 0.40-0.72; P < .001). The results were consistent in a secondary aggregate data meta-analysis including the ACS subgroup of additional randomized clinical trials which enrolled patients with ACS as well as chronic coronary syndrome. CONCLUSIONS In ACS patients undergoing DES implantation, ticagrelor monotherapy after short-term DAPT was associated with less major bleeding without a concomitant increase in ischaemic events compared with ticagrelor-based 12-month DAPT. STUDY REGISTRATION PROSPERO (ID: CRD42023476470).
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Affiliation(s)
- Yong-Joon Lee
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Sanghoon Shin
- Department of Cardiology, Ewha Womans University College of Medicine Seoul Hospital, Seoul, Korea
| | - Sung Woo Kwon
- Department of Cardiology, Inha University Hospital, Incheon, Korea
| | - Yongsung Suh
- Myongji Hospital, Hanyang University College of Medicine, 55 Hwasu-ro 14 beon-gil, Deokyang-gu, 10475 Goyang, Korea
| | - Kyeong Ho Yun
- Department of Cardiology, Wonkwang University Hospital, Iksan, Korea
| | - Tae Soo Kang
- Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Jun-Won Lee
- Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Deok-Kyu Cho
- Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jong-Kwan Park
- Department of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jang-Whan Bae
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Woong Cheol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Seunghwan Kim
- Department of Cardiology, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Seung-Jun Lee
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Sung-Jin Hong
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Chul-Min Ahn
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Jung-Sun Kim
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Byeong-Keuk Kim
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Young-Guk Ko
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Donghoon Choi
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA University College of Medicine, Seongnam, Korea
| | - Myeong-Ki Hong
- Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, 03722 Seoul, Korea
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8
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Yu S, Guo L, Guo H. Aspirin-free P2Y12 inhibitor monotherapy immediately after percutaneous coronary intervention: A systematic review. Heliyon 2024; 10:e35741. [PMID: 39170240 PMCID: PMC11336810 DOI: 10.1016/j.heliyon.2024.e35741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/26/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024] Open
Abstract
Background A modified antiplatelet therapy approach after percutaneous coronary intervention (PCI), specifically reducing dual antiplatelet therapy (DAPT) duration and transitioning to P2Y12 inhibitor monotherapy, may offer advantages in terms of bleeding risk reduction. However, the impact of initiating aspirin-free P2Y12 inhibitor monotherapy immediately after PCI is not yet fully understood. Methods We systematically searched the PubMed and Embase databases until January 2024 for studies that examined the use of P2Y12 inhibitor monotherapy as a treatment approach without initial DAPT following PCI. Results Four single-arm pilot prospective studies and 1 randomized controlled trial were included. In acute coronary syndrome patients with P2Y12 monotherapy following aspirin withdrawal immediately after PCI, the occurrence rates of the primary ischemic and bleeding endpoint were 2.91 % (8 out of 275 patients) and 1.09 % (3 out of 275 patients) respectively, whereas both the incidence rates of the primary ischemic and bleeding endpoints were 0.25 % (1 out of 407 patients) in individuals with stable coronary artery disease. In the STOPDAPT-3 trial comparing the effect of aspirin-free prasugrel monotherapy with standard DAPT after PCI, no differences were found in the primary ischemic or bleeding endpoints and most secondary outcomes (death, stroke, and myocardial infarction). However, there was an increased risk of coronary revascularization and stent thrombosis in the no-aspirin group. Conclusions Single-arm studies suggest the safety and feasibility of aspirin-free P2Y12 inhibitor monotherapy without initial DAPT after PCI in selected patients with acute coronary syndrome or stable coronary artery disease. However, the safety and efficacy of this aspirin-free approach compared with standard DAPT strategies following PCI still require further investigation.
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Affiliation(s)
- Shenglong Yu
- Department of Cardiovascular, the Affiliated Panyu Central Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Huizhuang Guo
- Department of Radiology, the Affiliated Panyu Central Hospital of Guangzhou Medical University, Guangzhou, China
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9
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Nelson MR, Black JA. Aspirin: latest evidence and developments. Heart 2024; 110:1069-1073. [PMID: 39074973 DOI: 10.1136/heartjnl-2024-323948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/03/2024] [Indexed: 07/31/2024] Open
Abstract
Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.
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Affiliation(s)
- Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - J Andrew Black
- Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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10
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Lee YJ, Cho DK, Lee JW, Shin S, Kwon SW, Suh Y, Kang TS, Park JK, Bae JW, Kang WC, Kim S, Lee SJ, Hong SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Yun KH, Hong MK. Ticagrelor monotherapy in ST-elevation myocardial infarction: An individual patient-level meta-analysis from TICO and T-PASS trials. MED 2024:S2666-6340(24)00301-5. [PMID: 39153473 DOI: 10.1016/j.medj.2024.07.019] [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: 03/18/2024] [Revised: 06/13/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) tend to be excluded or under-represented in randomized clinical trials evaluating the effects of potent P2Y12 inhibitor monotherapy after short-term dual antiplatelet therapy (DAPT). METHODS Individual patient data were pooled from randomized clinical trials that included STEMI patients undergoing drug-eluting stent (DES) implantation and compared ticagrelor monotherapy after short-term (≤3 months) DAPT versus ticagrelor-based 12-month DAPT in terms of centrally adjudicated clinical outcomes. The co-primary outcomes were efficacy outcome (composite of all-cause death, myocardial infarction, or stroke) and safety outcome (Bleeding Academic Research Consortium type 3 or 5 bleeding) at 1 year. FINDINGS The pooled cohort contained 2,253 patients with STEMI. The incidence of the primary efficacy outcome did not differ between the ticagrelor monotherapy group and the ticagrelor-based DAPT group (1.8% versus 2.0%; hazard ratio [HR] = 0.88; 95% confidence interval [CI] = 0.49-1.61; p = 0.684). There was no difference in cardiac death between the groups (0.6% versus 0.7%; HR = 0.89; 95% CI = 0.32-2.46; p = 0.822). The incidence of the primary safety outcome was significantly lower in the ticagrelor monotherapy group (2.3% versus 4.0%; HR = 0.56; 95% CI = 0.35-0.92; p = 0.020). No heterogeneity of treatment effects was observed for the primary outcomes across subgroups. CONCLUSIONS In patients with STEMI treated with DES implantation, ticagrelor monotherapy after short-term DAPT was associated with lower major bleeding without an increase in the risk of ischemic events compared with ticagrelor-based 12-month DAPT. Further research is necessary to extend these findings to non-Asian patients. FUNDING This study was funded by Biotronik (Bülach, Switzerland).
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Affiliation(s)
- Yong-Joon Lee
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Deok-Kyu Cho
- Department of Cardiology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Jun-Won Lee
- Department of Cardiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sanghoon Shin
- Department of Cardiology, Ewha Womans University College of Medicine Seoul Hospital, Seoul, Korea
| | - Sung Woo Kwon
- Department of Cardiology, Inha University Hospital, Incheon, Korea
| | - Yongsung Suh
- Department of Cardiology, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Tae Soo Kang
- Department of Cardiology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Jong-Kwan Park
- Department of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jang-Whan Bae
- Department of Cardiology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Woong Cheol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, Korea
| | - Seunghwan Kim
- Department of Cardiology, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Seung-Jun Lee
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Jin Hong
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul-Min Ahn
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung-Sun Kim
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong-Keuk Kim
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Department of Cardiology, CHA University College of Medicine, Seongnam, Korea
| | - Kyeong Ho Yun
- Department of Cardiology, Wonkwang University Hospital, Iksan, Korea.
| | - Myeong-Ki Hong
- Department of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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11
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Díez-Villanueva P, Jiménez-Méndez C, Cepas-Guillén P, Arenas-Loriente A, Fernández-Herrero I, García-Pardo H, Díez-Delhoyo F. Current Management of Non-ST-Segment Elevation Acute Coronary Syndrome. Biomedicines 2024; 12:1736. [PMID: 39200201 PMCID: PMC11352006 DOI: 10.3390/biomedicines12081736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/27/2024] [Accepted: 07/30/2024] [Indexed: 09/02/2024] Open
Abstract
Cardiovascular disease constitutes the leading cause of morbimortality worldwide. Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a common cardiovascular condition, closely related to the ageing population and significantly affecting survival and quality of life. The management of NSTE-ACS requires specific diagnosis and therapeutic strategies, thus highlighting the importance of a personalized approach, including tailored antithrombotic therapies and regimens, combined with timely invasive management. Moreover, specific and frequent populations in clinical practice, such as the elderly and those with chronic kidney disease, pose unique challenges in the management of NSTE-ACS due to their increased risk of ischemic and hemorrhagic complications. In this scenario, comprehensive management strategies and multidisciplinary care are of great importance. Cardiac rehabilitation and optimal management of cardiovascular risk factors are essential elements of secondary prevention since they significantly improve prognosis. This review highlights the need for a personalized approach in the management of NSTE-ACS, especially in vulnerable populations, and emphasizes the importance of precise antithrombotic management together with tailored revascularization strategies, as well as the role of cardiac rehabilitation in NSTE-ACS patients.
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Affiliation(s)
| | - César Jiménez-Méndez
- Cardiology Department, Hospital Universitario Puerta del Mar, 11009 Cádiz, Spain;
| | - Pedro Cepas-Guillén
- Cardiology Department, Hospital Clinic, 08036 Barcelona, Spain; (P.C.-G.); (A.A.-L.)
| | | | - Ignacio Fernández-Herrero
- Cardiology Department, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (I.F.-H.); (F.D.-D.)
| | - Héctor García-Pardo
- Cardiology Department, Hospital Universitario Río Hortega, 47012 Valladolid, Spain;
| | - Felipe Díez-Delhoyo
- Cardiology Department, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (I.F.-H.); (F.D.-D.)
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12
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Clifford C, Yan AT. After PCI and 1 mo of DAPT for ACS, ticagrelor alone vs. continued DAPT for 11 mo reduced bleeding without increasing MACCE. Ann Intern Med 2024; 177:JC86. [PMID: 39102721 DOI: 10.7326/annals-24-00968-jc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024] Open
Abstract
SOURCE CITATION Ge Z, Kan J, Gao X, et al; ULTIMATE-DAPT investigators. Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial. Lancet. 2024;403:1866-1878. 38599220.
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Affiliation(s)
- Cole Clifford
- University of Toronto, Toronto, Ontario, Canada (C.C.)
| | - Andrew T Yan
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.T.Y.)
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13
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Casula M, Casu G, Talanas G, Spano A, Tantry U, Bilotta F, Micheluzzi V, Merella P, Porcheddu T, Gorog DA, Bonaca M, Jeong YH, Farkouh ME, Kubica J, Isgender M, Gurbel PA, Navarese EP. Efficacy and Safety of P2Y 12 monotherapy vs standard DAPT in patients undergoing percutaneous coronary intervention: meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102635. [PMID: 38750991 DOI: 10.1016/j.cpcardiol.2024.102635] [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: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND Debates persist regarding the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in coronary artery disease (CAD). Recent trials have introduced a novel approach involving P2Y12 inhibitor monotherapy with ticagrelor or clopidogrel, after a short DAPT. However, the effectiveness and safety of this strategy remains to be established. We aimed to perform a meta-analysis comparing monotherapy with P2Y12 inhibitors versus standard DAPT in patients undergoing PCI at 12 months. METHODS Multiple databases were searched. Six RCTs with a total of 24877 patients were included. The primary endpoint was all-cause mortality at 12 months of follow-up. The secondary endpoints were cardiovascular mortality, myocardial infarction, probable or definite stent thrombosis, stroke events, and major bleeding. The study is registered with PROSPERO (CRD42024499529). RESULTS Monotherapy with P2Y12 inhibitor ticagrelor significantly reduced both allcause mortality (HR 0.71, 95 CI [0.55-0.91], P = 0.007) and cardiovascular mortality (HR 0.66, 95% CI [0.49-0.89], P = 0.006) compared to standard DAPT. In contrast, clopidogrel monotherapy did not demonstrate a similar reduction. The decrease in mortality associated with ticagrelor was primarily due to a lower risk of major bleeding (HR 0.56, 95% CI [0.43-0.72], P < 0.001), while the risk of myocardial infarction (MI) remained unchanged (HR 0.90, 95% CI [0.73-1.11], P = 0.32). The risk of stroke was found to be similar across treatments. CONCLUSIONS In comparison to standard DAPT, P2Y12 inhibitor monotherapy with ticagrelor may lead to a reduced mortality. The clinical benefits are driven by a reduction of bleeding risk without ischemic risk trade-off.
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Affiliation(s)
- Marta Casula
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Gavino Casu
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Giuseppe Talanas
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Andrea Spano
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Udaya Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ferruccio Bilotta
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Valentina Micheluzzi
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Pierluigi Merella
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Tomaso Porcheddu
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Diana A Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
| | - Marc Bonaca
- CPC Clinical Research, University of Colorado School of Medicine, USA
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University, Gwangmyeong Hospital, Gwangmyeong, South Korea; Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, South Korea
| | | | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mehriban Isgender
- Republican Clinical Hospital, Department of Cardiology, Azerbaijan Medical University, Department of Family Medicine, Baku, Azerbaijan
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Eliano Pio Navarese
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy.
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14
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Merdler I, Chitturi KR, Wermers JP, Salimes BG, Gray N, Chu W, Case BC, Ben-Dor I, Waksman R. Review of late-breaking clinical trials from Cardiovascular Research Technologies (CRT) 2024. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 65S:1-13. [PMID: 38796320 DOI: 10.1016/j.carrev.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Bailey G Salimes
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Nathan Gray
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Will Chu
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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15
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Clifford C, Yan AT. After PCI in older adults, DAPT for 3 vs. 6 or 12 mo reduces bleeding without increasing NACE or MACE. Ann Intern Med 2024; 177:JC87. [PMID: 39102718 DOI: 10.7326/annals-24-00961-jc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024] Open
Abstract
SOURCE CITATION Park DY, Hu JR, Jamil Y, et al. Shorter dual antiplatelet therapy for older adults after percutaneous coronary intervention: a systematic review and network meta-analysis. JAMA Netw Open. 2024;7:e244000. 38546647.
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Affiliation(s)
- Cole Clifford
- University of Toronto, Toronto, Ontario, Canada (C.C.)
| | - Andrew T Yan
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.T.Y.)
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16
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Lanthier L, Couture ÉL, Plourde MÉ, Cauchon M. [Among patients with acute coronary syndrome who underwent percutaneous coronary intervention with contemporary stents and had no ischemic or hemorrhagic events during 1 month on dual antiplatelet therapy, does treatment with ticagrelor alone between the 1st and 12th month reduce the risk of clinically relevant bleeding while remaining effective in preventing vascular complications compared to ticagrelor combined with aspirin?]. Rev Med Interne 2024:S0248-8663(24)00701-X. [PMID: 39034260 DOI: 10.1016/j.revmed.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Affiliation(s)
- Luc Lanthier
- Département de médecine spécialisé, service de médecine interne générale, université de Sherbrooke, 580, Bowen Sud, J1G 2E8 Sherbrooke, QC, Canada.
| | - Étienne L Couture
- Département de médecine spécialisé, service de cardiologie, université de Sherbrooke, Sherbrooke, QC, Canada
| | - Marc-Émile Plourde
- Département de médecine nucléaire et radiobiologie, service de radio-oncologie, université de Sherbrooke, Sherbrooke, QC, Canada
| | - Michel Cauchon
- Département de médecine nucléaire et radiobiologie, service de radio-oncologie, université de Sherbrooke, Sherbrooke, QC, Canada; Département de médecine familiale et de médecine d'urgence, université Laval, Québec, QC, Canada
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17
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Galli M, Costa F, Navarese EP. De-escalation versus shortening of dual antiplatelet therapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:267-269. [PMID: 38458235 DOI: 10.1093/ehjcvp/pvae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/03/2024] [Accepted: 03/07/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, 48033 Cotignola, RA, Italy
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Via Consolare Valeria 1, 98124 Messina, ME, Italy
| | - Eliano Pio Navarese
- Clinical Experimental Cardiology, University of Sassari, Piazza Università 21, 07100, Sassari, SS, Italy
- SIRIO MEDICINE Research Network
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18
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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; 41:2606-2634. [PMID: 38743242 PMCID: PMC11213809 DOI: 10.1007/s12325-024-02877-y] [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: 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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19
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Scorpiglione L, Pizzicannella J, Bacigalupi E, Cicchitti V, Pelliccia F, Foglietta M, Gallina S, Zimarino M. Therapeutic strategies aiming at the reduction of the antiplatelet intensity should not overlook the ischemic risk in patients with coronary syndromes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00546-3. [PMID: 38987047 DOI: 10.1016/j.carrev.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/22/2024] [Accepted: 06/17/2024] [Indexed: 07/12/2024]
Abstract
De-escalation of dual antiplatelet therapy (DAPT) is gaining traction as a strategy to reduce bleeding risks while ensuring ischemic outcomes. Undiscriminating de-escalation, notably in patients with high ischemic risk, might expose them to major adverse cardiac events. Platelet function and genetic tests are emerging tools to guide de-escalation, but both present specific drawbacks. Recent meta-analyses have aimed to consolidate the findings of individual trials to provide clearer insights. Yet, limitations remain for patients with concomitant high bleeding and ischemic risks. These high-risk patients are frequently underrepresented in clinical trials, and, therefore, currently available guidelines lack evidence-based recommendations for this subset. While DAPT de-escalation strategies hold promise, the choice of approach, whether clinically or assay-guided, remains complex and should be individualized.
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Affiliation(s)
- Luca Scorpiglione
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Jacopo Pizzicannella
- Department of Engineering and Geology, "G. d'Annunzio" University, Chieti-Pescara, Italy; Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy.
| | - Elena Bacigalupi
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Vincenzo Cicchitti
- Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | | | - Melissa Foglietta
- Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University, Chieti-Pescara, Italy; Department of Cardiology, "SS.Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
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20
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Finocchiaro S, Capodanno D. Rethinking Aspirin: Ditching the Daily "Pill"ar of Tradition. JACC Cardiovasc Interv 2024; 17:1246-1251. [PMID: 38811106 DOI: 10.1016/j.jcin.2024.04.020] [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: 03/17/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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21
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Ge Z, Kan J, Gao X, Raza A, Zhang JJ, Mohydin BS, Gao F, Shao Y, Wang Y, Zeng H, Li F, Khan HS, Mengal N, Cong H, Wang M, Chen L, Wei Y, Chen F, Stone GW, Chen SL. Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial. Lancet 2024; 403:1866-1878. [PMID: 38599220 DOI: 10.1016/s0140-6736(24)00473-2] [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: 02/11/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Following percutaneous coronary intervention with stent placement to treat acute coronary syndromes, international clinical guidelines generally recommend dual antiplatelet therapy with aspirin plus a P2Y12 receptor inhibitor for 12 months to prevent myocardial infarction and stent thrombosis. However, data on single antiplatelet therapy with a potent P2Y12 inhibitor earlier than 12 months after percutaneous coronary intervention for patients with an acute coronary syndrome are scarce. The aim of this trial was to assess whether the use of ticagrelor alone, compared with ticagrelor plus aspirin, could reduce the incidence of clinically relevant bleeding events without an accompanying increase in major adverse cardiovascular or cerebrovascular events (MACCE). METHODS In this randomised, placebo-controlled, double-blind clinical trial, patients aged 18 years or older with an acute coronary syndrome who completed the IVUS-ACS study and who had no major ischaemic or bleeding events after 1-month treatment with dual antiplatelet therapy were randomly assigned to receive oral ticagrelor (90 mg twice daily) plus oral aspirin (100 mg once daily) or oral ticagrelor (90 mg twice daily) plus a matching oral placebo, beginning 1 month and ending at 12 months after percutaneous coronary intervention (11 months in total). Recruitment took place at 58 centres in China, Italy, Pakistan, and the UK. Patients were required to remain event-free for 1 month on dual antiplatelet therapy following percutaneous coronary intervention with contemporary drug-eluting stents. Randomisation was done using a web-based system, stratified by acute coronary syndrome type, diabetes, IVUS-ACS randomisation, and site, using dynamic minimisation. The primary superiority endpoint was clinically relevant bleeding (Bleeding Academic Research Consortium [known as BARC] types 2, 3, or 5). The primary non-inferiority endpoint was MACCE (defined as the composite of cardiac death, myocardial infarction, ischaemic stroke, definite stent thrombosis, or clinically driven target vessel revascularisation), with an expected event rate of 6·2% in the ticagrelor plus aspirin group and an absolute non-inferiority margin of 2·5 percentage points between 1 month and 12 months after percutaneous coronary intervention. The two co-primary endpoints were tested sequentially; the primary superiority endpoint had to be met for hypothesis testing of the MACCE outcome to proceed. All principal analyses were assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT03971500, and is completed. FINDINGS Between Sept 21, 2019, and Oct 27, 2022, 3400 (97·0%) of the 3505 participants in the IVUS-ACS study were randomly assigned (1700 patients to ticagrelor plus aspirin and 1700 patients to ticagrelor plus placebo). 12-month follow-up was completed by 3399 (>99·9%) patients. Between month 1 and month 12 after percutaneous coronary intervention, clinically relevant bleeding occurred in 35 patients (2·1%) in the ticagrelor plus placebo group and in 78 patients (4·6%) in the ticagrelor plus aspirin group (hazard ratio [HR] 0·45 [95% CI 0·30 to 0·66]; p<0·0001). MACCE occurred in 61 patients (3·6%) in the ticagrelor plus placebo group and in 63 patients (3·7%) in the ticagrelor plus aspirin group (absolute difference -0·1% [95% CI -1·4% to 1·2%]; HR 0·98 [95% CI 0·69 to 1·39]; pnon-inferiority<0·0001, psuperiority=0·89). INTERPRETATION In patients with an acute coronary syndrome who had percutaneous coronary intervention with contemporary drug-eluting stents and remained event-free for 1 month on dual antiplatelet therapy, treatment with ticagrelor alone between month 1 and month 12 after the intervention resulted in a lower rate of clinically relevant bleeding and a similar rate of MACCE compared with ticagrelor plus aspirin. Along with the results from previous studies, these findings show that most patients in this population can benefit from superior clinical outcomes with aspirin discontinuation and maintenance on ticagrelor monotherapy after 1 month of dual antiplatelet therapy. FUNDING The Chinese Society of Cardiology, the National Natural Scientific Foundation of China, and the Jiangsu Provincial & Nanjing Municipal Clinical Trial Project. TRANSLATION For the Mandarin translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Zhen Ge
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jing Kan
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaofei Gao
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Afsar Raza
- Airdale General Hospital, West Yorkshire, UK
| | - Jun-Jie Zhang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | | | - Fentang Gao
- Gansu Provincial People's Hospital, Lanzhou, China
| | | | - Yan Wang
- Xiamen Heart Center, Xiamen University, Xiamen, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Li
- Affiliated Oriental Huainan General Hospital, Anhui University of Science and Technology, Huainan, China
| | | | - Naeem Mengal
- National Institute of Cardiovascular Diseases of Pakistan, Karaqi, Pakistan
| | - Hongliang Cong
- Tianjin Chest Hospital, Tianjin University, Tianjin, China
| | - Mingliang Wang
- Puto People's Hospital, Tongji University, Shanghai, China
| | | | - Yongyue Wei
- Center for Public Health and Epidemic Preparedness & Response, Peking University, Beijing, China
| | - Feng Chen
- School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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22
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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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23
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Licordari R, Costa F, Garcia-Ruiz V, Mamas MA, Marquis-Gravel G, de la Torre Hernandez JM, Gomez Doblas JJ, Jimenez-Navarro M, Rodriguez-Capitan J, Urbano-Carrillo C, Ortega-Paz L, Piccolo R, Versace AG, Di Bella G, Andò G, Angiolillo DJ, Valgimigli M, Micari A. The Evolving Field of Acute Coronary Syndrome Management: A Critical Appraisal of the 2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndrome. J Clin Med 2024; 13:1885. [PMID: 38610650 PMCID: PMC11012418 DOI: 10.3390/jcm13071885] [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: 02/19/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Acute coronary syndromes (ACS), encompassing conditions like ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndromes (NSTE-ACS), represent a significant challenge in cardiovascular care due to their complex pathophysiology and substantial impact on morbidity and mortality. The 2023 European Society of Cardiology (ESC) guidelines for ACS management introduce several updates in key areas such as invasive treatment timing in NSTE-ACS, pre-treatment strategies, approaches to multivessel disease, and the use of imaging modalities including computed tomography (CT) coronary angiography, magnetic resonance imaging (MRI), and intracoronary imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS). They also address a modulation of antiplatelet therapy, taking into consideration different patient risk profiles, and introduce new recommendations for low-dose colchicine. These guidelines provide important evidence-based updates in practice, reflecting an evolution in the understanding and management of ACS, yet some potentially missed opportunities for more personalized care and technology adoption are discussed.
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Affiliation(s)
- Roberto Licordari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
| | | | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele ST5 5BG, UK;
| | - Guillaume Marquis-Gravel
- Montréal Heart Institute, Faculty of Medicine, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | | | - Juan Jose Gomez Doblas
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | - Manuel Jimenez-Navarro
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | - Jorge Rodriguez-Capitan
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | | | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA (D.J.A.)
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | | | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (G.D.B.); (G.A.)
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (G.D.B.); (G.A.)
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA (D.J.A.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6500 Lugano, Switzerland;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
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24
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Storey RF. Antiplatelet Therapy After PCI: The Art and Science of De-Escalation. Circulation 2024; 149:601-604. [PMID: 38377261 DOI: 10.1161/circulationaha.123.067767] [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] [Indexed: 02/22/2024]
Affiliation(s)
- Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, University of Sheffield, United Kingdom (R.F.S.)
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom (R.F.S.)
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25
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Maqsood MH, Levine GN, Kleiman ND, Hasdai D, Uretsky BF, Birnbaum Y. Do We Still Need Aspirin in Coronary Artery Disease? J Clin Med 2023; 12:7534. [PMID: 38137601 PMCID: PMC10743767 DOI: 10.3390/jcm12247534] [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: 11/02/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Aspirin has for some time been used as a first-line treatment for acute coronary syndromes, including ST-elevation myocardial infarction, for secondary prevention of established coronary disease, and for primary prevention in patients at risk of coronary artery disease. Although aspirin has been in use for decades, the available evidence for its efficacy largely predates the introduction of other drugs, such as statins and P2Y12 inhibitors. Based on recent trials, the recommendation for aspirin use as primary prevention has been downgraded. In addition, P2Y12 inhibitors given as a single antiplatelet therapy have been associated with a lower incidence of bleeding than dual antiplatelet therapy in combination with aspirin in patients with stable and unstable coronary artery disease. The aim of this review is to discuss the role of aspirin considering the available evidence for primary prevention, secondary prevention for stable coronary artery disease or acute coronary syndromes, and after percutaneous coronary intervention or coronary artery bypass revascularization.
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Affiliation(s)
- Muhammad Haisum Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Methodist Hospital, Houston, TX 77030, USA;
| | - Glenn N. Levine
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Neal D. Kleiman
- Department of Cardiology, Section of Interventional Cardiology, Houston Methodist DeBakey Heart Center, Houston, TX 77030, USA;
| | - David Hasdai
- Department of Cardiology, Rabin Medical Center, Tel Aviv University, Petah Tikva 49200, Israel;
| | - Barry F. Uretsky
- Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
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