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Agbaedeng TA, Noubiap JJ, Roberts KA, Chew DP, Psaltis PJ, Amare AT. Sex-Based Outcomes of Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention: A Pairwise and Network Meta-Analysis. Drugs 2024:10.1007/s40265-024-02034-3. [PMID: 38809372 DOI: 10.1007/s40265-024-02034-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Although dual antiplatelet therapy (DAPT) improves the outcomes of patients undergoing percutaneous coronary intervention (PCI), sex-specific differences in efficacy and safety of DAPT remain unresolved. We compared sex differences for DAPT outcomes and DAPT durations (1-3 months [short-term], 6 months [mid-term], and >12 months [extended] vs. 12 months). METHODS We searched databases through 31 December 2023 for trials reporting DAPT after PCI. The endpoints were major adverse cardiovascular and cerebrovascular events (MACCE), net adverse clinical and cerebrovascular events (NACCE), and any bleeding. Extracted data were pooled in a frequentist network and pairwise, random-effects meta-analysis. RESULTS Twenty-two trials (99,591 participants, 25.2% female) were included. Female sex was significantly associated with a higher 1-year MACCE risk (hazard ratio 1.14 [95% confidence interval 1.02-1.28]) and bleeding (1.13 [1.00-1.28]), but not NACCE (1.12 [0.96-1.31]). In sub-analyses, the association between female sex and MACCE was related to use of clopidogrel as the second antiplatelet agent (1.11 [1.03-1.20]), whereas higher bleeding events were related to newer P2Y12 inhibitors (P2Y12i) (1.58 [1.01-2.46]). For DAPT duration, short-term DAPT followed by P2Y12i monotherapy was non-inferior for MACCE in females and males (0.95 [95% CI 0.83-1.10; and 0.96 [0.80-1.16]) but tended to be superior in males for NACCE versus 12-month DAPT (0.96 [0.91-1.01]); mid-term DAPT tended to be associated with a lower bleeding risk in males (0.43 [0.17-1.09]). CONCLUSIONS Female sex is associated with higher MACCE and bleeding when newer P2Y12i agents are used. Short-term DAPT followed by P2Y12i monotherapy is safe and effective in both sexes undergoing PCI. CLINICAL TRIALS REGISTRATION PROSPERO ID: CRD42021278663.
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Affiliation(s)
- Thomas A Agbaedeng
- Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Roosevelt Dr, Oxford, OX3 7BN, UK.
| | - Jean Jacques Noubiap
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Kirsty A Roberts
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Derek P Chew
- Monash Data Futures Institute, Monash University , Clayton, Victoria , Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Vascular Research Centre, Lifelong Health Theme, SAHMRI, Adelaide, SA, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Azmeraw T Amare
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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Numao Y, Takahashi S, Nakao YM, Tajima E, Noma S, Endo A, Honye J, Tsukada Y. Sex Differences in Bleeding Risk Associated With Antithrombotic Therapy Following Percutaneous Coronary Intervention. Circ Rep 2024; 6:99-109. [PMID: 38606417 PMCID: PMC11004037 DOI: 10.1253/circrep.cr-24-0015] [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: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/13/2024] Open
Abstract
Background: Antithrombotic therapy is crucial for secondary prevention of cardiovascular disease (CVD), but women with CVD may face increased bleeding complications post-percutaneous coronary intervention (PCI) under antithrombotic therapy. However, women are often underrepresented in clinical trials in this field, so evidence for sex-specific recommendations is lacking. Methods and Results: A search on PubMed was conducted for English-language articles addressing bleeding complications and antithrombotic therapy in women. Despite women potentially showing higher baseline platelet responsiveness than men, the clinical implications remain unclear. Concerning antiplatelet therapy post-PCI, although women have an elevated bleeding risk in the acute phase, no sex differences were observed in the chronic phase. However, women require specific considerations for factors such as age, renal function, and weight when determining the dose and duration of antiplatelet therapy. Regarding anticoagulation post-PCI, direct oral anticoagulants may pose a lower bleeding risk in women compared with warfarin. Concerning triple antithrombotic therapy (TAT) post-PCI for patients with atrial fibrillation, there is a lack of evidence on whether sex differences should be considered in the duration and regimen of TAT. Conclusions: Recent findings on sex differences in post-PCI bleeding complications did not provide enough evidence to recommend specific therapies for women. Further studies are needed to address this gap and recommend optimal antithrombotic therapy post-PCI for women.
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Affiliation(s)
- Yoshimi Numao
- Department of Cardiology, Itabashi Chuo Medical Center Tokyo Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Oiso Hospital Kanagawa Japan
| | - Yoko M Nakao
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University Kyoto Japan
| | - Emi Tajima
- Department of Cardiology, Tokyo General Hospital Tokyo Japan
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | - Ayaka Endo
- Department of Cardiology, Tokyo Saiseikai Central Hospital Tokyo Japan
| | - Junko Honye
- Cardiovascular Center, Kikuna Memorial Hospital Kanagawa Japan
| | - Yayoi Tsukada
- Department of General Medicine and Health Science, Nippon Medical School Tokyo Japan
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3
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Amoafo EB, Entsie P, Kang Y, Canobbio I, Liverani E. Platelet P2Y 12 signalling pathway in the dysregulated immune response during sepsis. Br J Pharmacol 2024; 181:532-546. [PMID: 37525937 PMCID: PMC10830899 DOI: 10.1111/bph.16207] [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] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
Sepsis is a complicated pathological condition in response to severe infection. It is characterized by a strong systemic inflammatory response, where multiple components of the immune system are involved. Currently, there is no treatment for sepsis. Blood platelets are known for their role in haemostasis, but they also participate in inflammation through cell-cell interaction and the secretion of inflammatory mediators. Interestingly, an increase in platelet activation, secretion, and aggregation with other immune cells (such as monocytes, T-lymphocytes and neutrophils) has been detected in septic patients. Therefore, antiplatelet therapy in terms of P2Y12 antagonists has been evaluated as a possible treatment for sepis. It was found that blocking P2Y12 receptors decreased platelet marker expression and limited attachment to immune cells in some studies, but not in others. This review addresses the role of platelets in sepsis and discusses whether antagonizing P2Y12 signalling pathways can alter the disease outcome. Challenges in studying P2Y12 antagonists in sepsis also are discussed. LINKED ARTICLES: This article is part of a themed issue on Platelet purinergic receptor and non-thrombotic disease. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.4/issuetoc.
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Affiliation(s)
- Emmanuel Boadi Amoafo
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Philomena Entsie
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Ying Kang
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
| | - Ilaria Canobbio
- Department of Biology and Biotechnology, University of Pavia, Pavia, Italy
| | - Elisabetta Liverani
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA
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4
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Abstract
Antiplatelet therapy is a cornerstone of secondary prevention of cardiovascular diseases (CVDs). However, current guidelines are based on data derived primarily from men, as women are generally underrepresented in trials. Consequently, there are insufficient and inconsistent data on the effect of antiplatelet drugs in women. Sex differences were reported in platelet reactivity, patient management, and clinical outcomes after treatment with aspirin, P2Y12 inhibitor, or dual antiplatelet therapy. To evaluate whether sex-specific antiplatelet therapy is needed, in this review we discuss (i) how sex affects platelet biology and response to antiplatelet agents, (ii) how sex and gender differences translate into clinical challenges and (iii) how the cardiological care in women might be improved. Finally, we highlight the challenges faced in clinical practice regarding the different needs and characteristics of female and male patients with CVD and address issues requiring further investigation.
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Affiliation(s)
- Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Independent Public Central Teaching Hospital, Warsaw, Poland
| | - Jakub M Zimodro
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Independent Public Central Teaching Hospital, Warsaw, Poland
| | - Yolande Appelman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
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5
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Elertson KM, Morgan LL. Consideration of Gender in Cardiovascular Disease Prevention and Management. Nurs Clin North Am 2023; 58:595-605. [PMID: 37833001 DOI: 10.1016/j.cnur.2023.06.003] [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: 10/15/2023]
Abstract
According to the World Health Organization, heart disease is the leading cause of death worldwide, accounting for approximately 17.9 million deaths annually. Although both men and women experience heart disease, there are notable differences in pathophysiology, evaluation, and pharmacologic management related to biological sex and gender. Men are more likely to develop heart disease at younger ages with more severe presentations. Women usually develop heart disease later in life and have more subtle symptoms, including microvascular involvement. It is essential that providers are aware of gender disparities, social determinants, and modifiable risk factors in prevention of heart disease.
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Affiliation(s)
- Kathleen M Elertson
- University of Wisconsin Oshkosh, College of Nursing, 800 Algoma Boulevard, Oshkosh, WI 54901, USA.
| | - Lindsay L Morgan
- University of Wisconsin Oshkosh, College of Nursing, 800 Algoma Boulevard, Oshkosh, WI 54901, USA
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6
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Shin ES, Her AY, Kim B, Hahn JY, Song YB, Lee JM, Park TK, Yang JH, Choi JH, Choi SH, Lee SH, Gwon HC. Sex-Based Outcomes of P2Y12 Inhibitor Monotherapy After Three Months of Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention. J Korean Med Sci 2023; 38:e383. [PMID: 37987108 PMCID: PMC10659928 DOI: 10.3346/jkms.2023.38.e383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 08/22/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI) in the SMART-CHOICE trial, P2Y12 inhibitor monotherapy after three months of dual antiplatelet therapy (DAPT) achieved clinical outcomes comparable to those of 12 months of DAPT. Nonetheless, the effects of sex on these outcomes remain unknown. METHODS This open-label, non-inferiority, randomized study, conducted in 33 hospitals in South Korea, included 2,993 patients undergoing PCI with drug-eluting stents. Patients were randomly assigned to receive DAPT (aspirin plus a P2Y12 inhibitor) for three months then P2Y12 inhibitor alone for nine months, or DAPT for the entire 12 months. The primary endpoints were major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) 12 months after the index procedure. The bleeding endpoints were Bleeding Academic Research Consortium (BARC) bleeding types 2 to 5. RESULTS Of the patients, 795 (26.6%) were women, who were older and had a higher prevalence of hypertension, diabetes, and dyslipidemia than men. The sexes exhibited comparable primary endpoints (adjusted hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.55-1.55; P = 0.770) and bleeding endpoints (adjusted HR, 1.07; 95% CI, 0.63-1.81; P = 0.811). P2Y12 inhibitor monotherapy vs DAPT was associated with lower risk of BARC type 2 to 5 bleeding in women (adjusted HR, 0.40; 95% CI, 0.16-0.98; P = 0.045) but the difference was not statistically significant when using the Bonferroni correction. The primary endpoints were similar between treatment groups in both sexes. CONCLUSION In both sexes undergoing PCI, P2Y12 inhibitor monotherapy after three months of DAPT achieved similar risks of the primary endpoints and the bleeding events compared with prolonged DAPT. Therefore, the benefits of early aspirin withdrawal with ongoing P2Y12 inhibitors may be comparable in women and men. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02079194.
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Affiliation(s)
- Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University College of Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Bitna Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hoon Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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7
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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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8
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Jang MH, Kim AR, Kim T, Oh HJ, Lee JH, Lee YJ, Kim S, Lee J, Kim JH, Cha SJ, Kim TO, Kang DY, Lee PH, Ahn JM, Park DW, Park SJ. Age- and Sex-Specific Disparities in Outcomes After Ticagrelor Versus Clopidogrel in East Asian Patients. Am J Cardiol 2023; 207:237-244. [PMID: 37757520 DOI: 10.1016/j.amjcard.2023.08.124] [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: 05/29/2023] [Revised: 08/15/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023]
Abstract
It is unknown whether there are age- and gender-related differences in the safety and efficacy of potent P2Y12 inhibitors in East Asian populations with a different bleeding or ischemic propensity. Using data from the TICAKOREA (Ticagrelor Versus Clopidogrel in Asian/Korean Patients with ACS Intended for Invasive Management) trial comparing ticagrelor versus clopidogrel for 800 Korean patients with acute coronary syndrome, the safety and efficacy outcomes were compared according to age (<75 vs ≥75 years) and gender (men vs women). The primary bleeding end point was clinically significant bleeding, and the primary ischemic end point was a major adverse cardiovascular event (MACE) at 12 months. The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in patients aged <75 years (adjusted hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.40 to 4.67) but not in patients aged ≥75 years (adjusted HR 1.1, 95% CI 0.40 to 3.38). The incidences of MACEs were significantly higher after ticagrelor than after clopidogrel in patients aged ≥75 years (adjusted HR 6.14, 95% CI 1.40 to 26.90) but not in patients aged <75 years (adjusted HR 0.93, 95% CI 0.50 to 1.73). The incidences of clinically significant bleeding were significantly higher after ticagrelor than after clopidogrel in men (adjusted HR 2.69, 95% CI 1.38 to 5.24) but not in women (adjusted HR 1.49, 95% CI 0.64 to 3.46). The adjusted risks of MACEs after ticagrelor or clopidogrel were not significantly different between men and women. In conclusion, there were substantial age- and gender-related differences in bleeding and ischemic outcomes after ticagrelor or clopidogrel in Korean patients with acute coronary syndrome. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique identifier: NCT02094963.
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Affiliation(s)
- Mi Hee Jang
- Department of Cardiology, Ulsan University Hospital, Ulsan, Korea
| | - Ah-Ram Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taesun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon Jeong Oh
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeen Hwa Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Jeong Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyeon Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Joo Cha
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Burgess SN, Shoaib A, Sharp ASP, Ludman P, Graham MM, Figtree GA, Kontopantelis E, Rashid M, Kinnaird T, Mamas MA. Sex-Specific Differences in Potent P2Y 12 Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI Patients. Circ Cardiovasc Interv 2023; 16:e012447. [PMID: 37725676 DOI: 10.1161/circinterventions.122.012447] [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: 10/19/2022] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Sex-based outcome differences for women with ST-segment-elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y12 inhibitors (P-P2Y12) is not well defined. This study explores the hypothesis that disparities in P-P2Y12 (prasugrel or ticagrelor) use may play a role in outcome disparities for women with STEMI. METHODS Data from British Cardiovascular Intervention Society national percutaneous coronary intervention database were analyzed, and 168 818 STEMI patients treated with primary percutaneous coronary intervention from 2010 to 2020 were included. RESULTS Among the included women (43 131; 25.54%) and men (125 687; 74.45%), P-P2Y12 inhibitors were prescribed less often to women (51.71%) than men (55.18%; P<0.001). Women were more likely to die in hospital than men (adjusted odds ratio, 1.213 [95% CI, 1.141-1.290]). Unadjusted mortality was higher among women treated with clopidogrel (7.57%), than P-P2Y12-treated women (5.39%), men treated with clopidogrel (4.60%), and P-P2Y12-treated men (3.61%; P<0.001). The strongest independent predictor of P-P2Y12 prescription was radial access (adjusted odds ratio, 2.368 [95% CI, 2.312-2.425]), used in 67.93% of women and 74.38% of men (P<0.001). Two risk adjustment models were used. Women were less likely to receive a P-P2Y12 (adjusted odds ratio, 0.957 [95% CI, 0.935-0.979]) with risk adjustment for baseline characteristics alone, when procedural factors including radial access were included in the model differences were not significant (adjusted odds ratio, 1.015 [95% CI, 0.991-1.039]). CONCLUSIONS Women were less likely to be prescribed prasugrel or ticagrelor, were less likely to have radial access, and had a higher mortality when being treated for STEMI. Improving rates of P-P2Y12 use and radial access may decrease outcome disparities for women with STEMI.
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Affiliation(s)
- Sonya N Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia (S.N.B.)
- University of Sydney, NSW, Australia (S.N.B.)
| | - Ahmad Shoaib
- Victoria Heart Institute Foundation (A.S.), Victoria, BC, Canada
- Royal Jubilee Hospital (A.S.), Victoria, BC, Canada
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
- Birmingham City Hospital, United Kingdom (A.S.)
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.L.)
| | - Michelle M Graham
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.)
| | - Gemma A Figtree
- Department of Cardiology, Kolling Institute, Royal North Shore Hospital and University of Sydney, Australia (G.A.F.)
| | | | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
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10
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Occhipinti G, Greco A, Angiolillo DJ, Capodanno D. Gender differences in efficacy and safety of antiplatelet strategies for acute coronary syndromes. Expert Opin Drug Saf 2023; 22:669-683. [PMID: 37542468 DOI: 10.1080/14740338.2023.2245331] [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: 05/28/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) represents the cornerstone of secondary prevention in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention. Despite its undisputed efficacy in reducing thrombotic events, DAPT increases the risk of bleeding, which is associated with higher morbidity and mortality. Novel antiplatelet strategies (i.e. in terms of timing, selection of drugs and their combinations, and modulation strategies) have been tested in randomized trials, suggesting the utility of tailored approaches in selected populations (i.e. patients at high bleeding or ischemic risk). It remains uncertain whether the effect of these strategies is influenced by sex. AREAS COVERED This narrative review provides an overview of available evidence surrounding sex differences in the efficacy and safety of antiplatelet strategies for ACS and analyzes the potential reasons behind these findings. Relevant content was searched for in PubMed. EXPERT OPINION Significant differences between women and men exist in terms of clinical presentation, pharmacotherapies, interventional management, and prognosis of ACS. However, these observations do not appear to be attributed to different pharmacodynamic effects of antiplatelet therapies between women and men. Unfortunately, a critical issue depends on women being often underrepresented in clinical trials, leading to a substantial lack of sex-specific evidence.
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Affiliation(s)
- Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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11
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Entsie P, Kang Y, Amoafo EB, Schöneberg T, Liverani E. The Signaling Pathway of the ADP Receptor P2Y12 in the Immune System: Recent Discoveries and New Challenges. Int J Mol Sci 2023; 24:ijms24076709. [PMID: 37047682 PMCID: PMC10095349 DOI: 10.3390/ijms24076709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
P2Y12 is a G-protein-coupled receptor that is activated upon ADP binding. Considering its well-established role in platelet activation, blocking P2Y12 has been used as a therapeutic strategy for antiplatelet aggregation in cardiovascular disease patients. However, receptor studies have shown that P2Y12 is functionally expressed not only in platelets and the microglia but also in other cells of the immune system, such as in monocytes, dendritic cells, and T lymphocytes. As a result, studies were carried out investigating whether therapies targeting P2Y12 could also ameliorate inflammatory conditions, such as sepsis, rheumatoid arthritis, neuroinflammation, cancer, COVID-19, atherosclerosis, and diabetes-associated inflammation in animal models and human subjects. This review reports what is known about the expression of P2Y12 in the cells of the immune system and the effect of P2Y12 activation and/or inhibition in inflammatory conditions. Lastly, we will discuss the major problems and challenges in studying this receptor and provide insights on how they can be overcome.
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Affiliation(s)
- Philomena Entsie
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
| | - Ying Kang
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
| | - Emmanuel Boadi Amoafo
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
| | - Torsten Schöneberg
- Division of Molecular Biochemistry, Rudolf Schönheimer Institute of Biochemistry, Medical Faculty, Leipzig University, 04103 Leipzig, Germany
| | - Elisabetta Liverani
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND 58105, USA
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12
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ten Haaf ME, van Geuns RJM, van der Linden MM, Smits PC, de Vries AG, Doevendans PA, Appelman Y, Boersma E. Sex-Related Bleeding Risk in Acute Coronary Syndrome Patients Receiving Dual Antiplatelet Therapy with Aspirin and a P2Y12 Inhibitor. Med Princ Pract 2023; 32:200-208. [PMID: 36948164 PMCID: PMC10601701 DOI: 10.1159/000529863] [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: 07/19/2022] [Accepted: 02/06/2023] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE The aim of this work was to study sex differences in major bleeding risk in relation to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). METHODS AND RESULTS The Rijnmond Collective Cardiology Research registry was designed to evaluate the application and outcomes of DAPT after ACS/PCI in the Rijnmond region in the Netherlands. Overall, 1,172 women (median age 67.5 years) and 3,087 men (median age 62.2 years) with ACS/PCI were enrolled between August 2011 and June 2013. Based on a tailored regional DAPT guideline aiming at bleeding risk minimization, 52.6% women and 66.9% men received prasugrel as first-choice P2Y12 inhibitor, in addition to aspirin. Women more frequently had contraindications for the use of prasugrel (and therefore received clopidogrel) than men (47.9 vs. 26.9%, p < 0.001). Femoral access was more common in women than in men (47.6 vs. 38.1%, p < 0.001). Women had higher incidence of major bleeding at 1 year than men (2.6 vs. 1.6%, p = 0.018). After adjustment for established bleeding risk factors, female sex was associated with over two-fold higher risk of major bleeding (adjusted hazard ratio 2.33; 95% confidence interval 1.26-4.32). This difference was apparent at discharge and appeared to be caused by access site bleedings (0.9 vs. 0.1%, p < 0.001). No sex differences were found in non-access site-related major bleeding up to 1 year. CONCLUSION Women with ACS/PCI receiving DAPT had higher major bleeding risk caused by an excess in access site bleeds, mainly in relation to the femoral approach.
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Affiliation(s)
- Monique E. ten Haaf
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- The Netherlands Heart Institute, Utrecht, The Netherlands
| | | | | | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Arie G. de Vries
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Pieter A. Doevendans
- The Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
- Cardiovascular Research School Erasmus University Rotterdam (COEUR), Rotterdam, The Netherlands
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13
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Kumar A, Lutsey PL, St Peter WL, Schommer JC, Van't Hof JR, Rajpurohit A, Farley JF. Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome: A Propensity Score-Matched Cohort Study. Clin Pharmacol Ther 2023; 113:401-411. [PMID: 36399019 PMCID: PMC9877194 DOI: 10.1002/cpt.2797] [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: 05/13/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
Comparative effectiveness evaluation of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared with clopidogrel after acute coronary syndrome (ACS) is limited in real-world US populations. The objective of this study was to evaluate cardiovascular events based on ticagrelor, prasugrel, and clopidogrel use in a real-world patient setting. This retrospective cohort study used the IBM MarketScan database (January 1, 2013, to December 31, 2018) to create three propensity score-matched pairs: ticagrelor vs. clopidogrel (N = 21,719), prasugrel vs. clopidogrel (N = 11,513), and prasugrel vs. ticagrelor (N = 11,065). The primary outcome was a composite of myocardial ischemia, unstable angina, stroke, and heart failure hospitalization. These groups were compared in a time-to-event analysis for the primary outcome at 30, 90, and 180 days following P2Y12 inhibitors initiation after percutaneous coronary intervention. Compared with clopidogrel, ticagrelor use suggested a 10% reduction in the primary outcome at 90 days (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). There were no differences for all other matched pairs or follow-up combinations. In the subgroup analysis of females, the results suggested a risk reduction of 27% for prasugrel at 30 days (HR: 0.73, 95% CI: 0.53-1.00) and 17% for ticagrelor at 90 days (HR: 0.83, 95% CI: 0.70-0.98) when compared with clopidogrel. Among patients treated with bare-metal stents, the results suggested that prasugrel vs. ticagrelor was associated with a 55% and 33% reduced risk for the primary outcome at 30 days and 180 days, respectively. With limited evidence in the United States comparing these drugs, this study helps inform clinicians when choosing P2Y12 inhibitors after ACS.
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Affiliation(s)
- Arun Kumar
- Department of Pharmacy Practice & Administrative SciencesJames L. Winkle College of Pharmacy, University of CincinnatiCincinnatiOhioUSA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthSchool of Public Health, University of MinnesotaMinneapolisMinnesotaUSA
| | - Wendy L. St Peter
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jon C. Schommer
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jeremy R. Van't Hof
- Cardiovascular Division and Lillehei Heart InstituteUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Abhijeet Rajpurohit
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Joel F. Farley
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
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14
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Burgess SN, Mamas MA. Narrowing disparities in PCI outcomes in women; From risk assessment, to referral pathways and outcomes. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 24:100225. [PMID: 38560635 PMCID: PMC10978432 DOI: 10.1016/j.ahjo.2022.100225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 04/04/2024]
Abstract
This review evaluates published data regarding outcomes for women with ACS undergoing PCI. Data is discussed from a patient centred perspective and timeline, beginning with sex-based differences in perception of risk, time to presentation, time to treatment, access to angiography, access to angioplasty, the impact of incomplete revascularization, prescribing practices, under-representation of women in randomized controlled trials and in cardiology physician workforces. The objective of the review is to identify factors contributing to outcome disparities for women with ACS, and to discuss potential solutions to close this outcome gap.
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Affiliation(s)
- Sonya N. Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia
- University of Sydney, NSW, Australia
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, UK
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15
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Zhang W, Zhang H. Effects of comprehensive nursing intervention based on self-disclosure on improving alexithymia in elder patients with coronary heart disease. BMC Nurs 2022; 21:216. [PMID: 35932024 PMCID: PMC9354330 DOI: 10.1186/s12912-022-01006-w] [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: 05/12/2021] [Accepted: 07/30/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Patients with coronary heart disease (CHD) experience stress and suffer from the risk of recurrence and death. Comprehensive nursing intervention based on self-disclosure (CNISD) is an interdisciplinary service and an effective approach to care that improves quality of life and alleviates suffering for patients with CHD. The purpose of this study was to analyze the effects of CNISD on alexithymia in patients with CHD. METHODS A total of 1088 patients with CHD were recruited and received CNISD (n = 540) and usual care (n = 548). The quality of life, alexithymia, four statutory health insurance funds, recurrence, mortality, and satisfaction was compared in patients with CHD between CNISD and usual care group. RESULTS Outcomes showed that CNISD improved sleep quality and quality of life, increased physical activity, reduced the hospital anxiety and depression scale in patients with CHD compared to usual care. Recurrence and mortality of patients with CHD were markedly improved by CNISD compared to patients with CHD in usual care group. CONCLUSIONS In conclusion, data in this study indicate that CNISD presents benefits in improving quality of life, physical activity, anxiety, depression, recurrence, and mortality for patients with CHD.
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Affiliation(s)
- Weixin Zhang
- Nursing School of Qiqihar Medical University, No 333, BuKui North Street, Jianhua District, Heilongjiang Province, 161006, Qiqihar City, China
| | - Haili Zhang
- Nursing School of Qiqihar Medical University, No 333, BuKui North Street, Jianhua District, Heilongjiang Province, 161006, Qiqihar City, China.
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16
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Shah T, Kapadia S, Lansky AJ, Grines CL. ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes. Curr Cardiol Rep 2022; 24:529-540. [PMID: 35286662 DOI: 10.1007/s11886-022-01676-7] [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] [Accepted: 02/03/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men. RECENT FINDINGS This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.
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Affiliation(s)
- Tayyab Shah
- Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA.
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17
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Chen S, Li J, Qiu M, Ma S, Jiang Z, Na K, Qi Z, Li Y, Li Y, Han Y. Predictors and long-term outcomes of in-hospital switching from clopidogrel to ticagrelor among patients with acute coronary syndrome undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2022; 99 Suppl 1:1424-1431. [PMID: 35077608 DOI: 10.1002/ccd.30089] [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: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/11/2022]
Abstract
This study evaluated clinical outcomes of switching from clopidogrel to ticagrelor in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). The clinical benefit of in-hospital switching from clopidogrel to ticagrelor in these patients remains unclear. Among patients with ACS initially receiving clopidogrel, logistic regression was used to identify independent predictors of switching to ticagrelor. Multivariable Cox regression was used to compare efficacy and safety between switching to ticagrelor and continuing clopidogrel. The primary endpoint was net adverse clinical events (NACEs) at 12 months, a composite of major adverse cardiovascular events (MACE) and Bleeding Academic Research Consortium (BARC) type 2/3/5 bleeding. Among 10,519 patients initially receiving clopidogrel, 1405 (13.4%) were switched to ticagrelor at discharge. Stent number, left main artery lesions, diabetes, male sex, age, estimated glomerular filtration rate of <45 ml/min/1.73 m2 , and history of PCI or stroke were identified as independent predictors of switching to ticagrelor. The rate of NACE (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.18-1.91) or BARC type 2/3/5 bleeding (HR: 2.01; 95% CI: 1.52-2.66) was significantly higher in patients switching to ticagrelor than in those continuing clopidogrel. The risk of MACE was comparable between both the groups (HR: 0.71; 95% CI: 0.41-1.22). In real-world practice, in-hospital switching from clopidogrel to ticagrelor was independently associated with several clinical factors. Patients switching to ticagrelor had a higher rate of NACE or BARC type 2/3/5 bleeding than those continuing clopidogrel, without any reduction in the MACE rate.
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Affiliation(s)
- Sanbao Chen
- General Hospital of Northern Theater Command of China Medical University, Shenyang, China.,Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,The Graduate School of Harbin Medical University, Harbin, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zaixin Jiang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yuzhuo Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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18
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Amoafo EB, Entsie P, Albayati S, Dorsam GP, Kunapuli SP, Kilpatrick LE, Liverani E. Sex-related differences in the response of anti-platelet drug therapies targeting purinergic signaling pathways in sepsis. Front Immunol 2022; 13:1015577. [PMID: 36405709 PMCID: PMC9667743 DOI: 10.3389/fimmu.2022.1015577] [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: 08/09/2022] [Accepted: 10/10/2022] [Indexed: 01/24/2023] Open
Abstract
Sepsis, a complex clinical syndrome resulting from a serious infection, is a major healthcare problem associated with high mortality. Sex-related differences in the immune response to sepsis have been proposed but the mechanism is still unknown. Purinergic signaling is a sex-specific regulatory mechanism in immune cell physiology. Our studies have shown that blocking the ADP-receptor P2Y12 but not P2Y1 receptor was protective in male mice during sepsis, but not female. We now hypothesize that there are sex-related differences in modulating P2Y12 or P2Y1 signaling pathways during sepsis. Male and female wild-type (WT), P2Y12 knock-out (KO), and P2Y1 KO mice underwent sham surgery or cecal ligation and puncture (CLP) to induce sepsis. The P2Y12 antagonist ticagrelor or the P2Y1 antagonist MRS2279 were administered intra-peritoneally after surgery to septic male and female mice. Blood, lungs and kidneys were collected 24 hours post-surgery. Sepsis-induced changes in platelet activation, secretion and platelet interaction with immune cells were measured by flow cytometry. Neutrophil infiltration in the lung and kidney was determined by a myeloperoxidase (MPO) colorimetric assay kit. Sepsis-induced platelet activation, secretion and aggregate formation were reduced in male CLP P2Y12 KO and in female CLP P2Y1 KO mice compared with their CLP WT counterpart. Sepsis-induced MPO activity was reduced in male CLP P2Y12 KO and CLP P2Y1 KO female mice. CLP males treated with ticagrelor or MRS2279 showed a decrease in sepsis-induced MPO levels in lung and kidneys, aggregate formation, and platelet activation as compared to untreated male CLP mice. There were no differences in platelet activation, aggregate formation, and neutrophil infiltration in lung and kidney between female CLP mice and female CLP mice treated with ticagrelor or MRS2279. In human T lymphocytes, blocking P2Y1 or P2Y12 alters cell growth and secretion in vitro in a sex-dependent manner, supporting the data obtained in mice. In conclusion, targeting purinergic signaling represents a promising therapy for sepsis but drug targeting purinergic signaling is sex-specific and needs to be investigated to determine sex-related targeted therapies in sepsis.
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Affiliation(s)
- Emmanuel Boadi Amoafo
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, United States
| | - Philomena Entsie
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, United States
| | - Samara Albayati
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Temple University Hospital, Philadelphia, PA, United States
| | - Glenn P Dorsam
- Center for Inflammation and Lung Research, Department of Microbiology, Immunology and Inflammation, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Satya P Kunapuli
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Temple University Hospital, Philadelphia, PA, United States
| | - Laurie E Kilpatrick
- Department of Microbiological Sciences, College of Agriculture, Food Systems and Natural Resources, North Dakota State University, Fargo, ND, United States
| | - Elisabetta Liverani
- Department of Pharmaceutical Sciences, School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, United States.,Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Temple University Hospital, Philadelphia, PA, United States
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19
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Thakkar A, Agarwala A, Michos ED. Secondary Prevention of Cardiovascular Disease in Women: Closing the Gap. Eur Cardiol 2021; 16:e41. [PMID: 34815749 PMCID: PMC8591616 DOI: 10.15420/ecr.2021.24] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
Cardiovascular disease (CVD) remains the leading cause of death in women globally. Younger women (<55 years of age) who experience MI are less likely to receive guideline-directed medical therapy (GDMT), have a greater likelihood of readmission and have higher rates of mortality than similarly aged men. Women have been under-represented in CVD clinical trials, which limits the generalisability of results into practice. Available evidence indicates that women derive a similar benefit as men from secondary prevention pharmacological therapies, such as statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, icosapent ethyl, antiplatelet therapy, sodium–glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists. Women are less likely to be enrolled in cardiac rehabilitation programs than men. Mitigating risk and improving outcomes is dependent on proper identification of CVD in women, using appropriate GDMT and continuing to promote lifestyle modifications. Future research directed at advancing our understanding of CVD in women will allow us to further develop and tailor CVD guidelines appropriate by sex and to close the gap between diagnoses, treatment and mortality.
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Affiliation(s)
- Aarti Thakkar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine Baltimore, MD, US
| | - Anandita Agarwala
- Division of Cardiology, Baylor Scott and White Health Heart Hospital Baylor Plano Plano, TX, US
| | - Erin D Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine Baltimore, MD, US
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20
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Al Raisi S, Protty M, Raposeiras-Roubín S, D'Ascenzo F, Abu-Assi E, Ariza-Solé A, Manzano-Fernández S, Templin C, Velicki L, Xanthopoulou I, Cerrato E, Quadri G, Rognoni A, Boccuzzi G, Montabone A, Taha S, Durante A, Gili S, Magnani G, Autelli M, Grosso A, Flores-Blanco P, Varbella F, Cespón-Fernández M, Gallo D, Morbiducci U, Domínguez-Rodríguez A, Cequier Á, Gaita F, Alexopoulos D, Valgimigli M, Íñiguez-Romo A, Kinnaird T. Ticagrelor versus prasugrel in acute coronary syndrome: sex-specific analysis from the RENAMI Registry. Minerva Cardiol Angiol 2021; 69:408-416. [PMID: 34137238 DOI: 10.23736/s2724-5683.21.05591-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of potent P2Y12 inhibitors (ticagrelor & prasugrel) in acute coronary syndrome (ACS) patients undergoing percutaneous coronary interventions (PCI) is a class I recommendation. We performed a sex-specific analysis comparing the difference in efficacy and safety outcomes between ticagrelor and prasugrel in a real-world ACS population. METHODS Data from the multicenter REgistry of New Antiplatelets in patients with Myocardial Infarction (RENAMI) for 4424 ACS patients who underwent PCI and were treated with ticagrelor or prasugrel between 2012 to 2016 were analyzed. Mean follow-up was 17±9 months. RESULTS After propensity score matching, there was no significant difference in the occurrence of primary endpoint of net adverse cardiac events between ticagrelor and prasugrel in men (HR: 0.94; 95% CI: 0.69-1.29; P=0.71), or women (HR: 1.17; 95% CI: 0.63-2.20; P=0.62; P interaction [sex] = 0.40). Similarly, no differences were found in the occurrence of any of the secondary endpoints (MACE, all cause death, re-infarction, stent thrombosis, BARC major bleeding and BARC any bleeding) between the two P2Y12 groups between men and women. CONCLUSIONS In this real-world ACS population, no relative difference in efficacy or safety outcomes were found between ticagrelor and prasugrel between sexes.
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Affiliation(s)
- Sara Al Raisi
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales, UK
| | - Majd Protty
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales, UK.,Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | | | - Fabrizio D'Ascenzo
- Service of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Emad Abu-Assi
- Department of Cardiology, Álvaro Cunqueiro University Hospital, Vigo, Pontevedra, Spain
| | | | | | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Lazar Velicki
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Institute of Cardiovascular Diseases Voivodina, Sremska Kamenica, Serbia
| | | | - Enrico Cerrato
- Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Giorgio Quadri
- Department of Cardiology, Infermi Hospital, Rivoli, Turin, Italy
| | - Andrea Rognoni
- Coronary Care Unit and Catheterization Laboratory, Maggiore della Carità University Hospital, Novara, Italy
| | | | | | - Salma Taha
- Department of Cardiology, Faculty of Medicine, Assiut University, Asiut, Egypt
| | | | - Sebastiano Gili
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Giulia Magnani
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Michele Autelli
- Service of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Grosso
- Service of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Pedro Flores-Blanco
- Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | | | - Diego Gallo
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Polytechnical University of Turin, Turin, Italy
| | - Umberto Morbiducci
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Polytechnical University of Turin, Turin, Italy
| | | | - Ángel Cequier
- Department of Cardiology, Bellvitge Hospital, Barcelona, Spain
| | - Fiorenzo Gaita
- Service of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Marco Valgimigli
- Service of Cardiology, University Hospital of the Canary Islands, Santa Cruz de Tenerife, Spain
| | - Andrés Íñiguez-Romo
- Coronary Care Unit and Catheterization Laboratory, Maggiore della Carità University Hospital, Novara, Italy
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales, UK -
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21
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Gao QN. Efficacy of ticagrelor in the treatment of stable coronary heart disease: A protocol of systematic review. Medicine (Baltimore) 2020; 99:e22600. [PMID: 33157917 PMCID: PMC7647616 DOI: 10.1097/md.0000000000022600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study will assess the efficacy and safety of ticagrelor in the treatment of patients with stable coronary heart disease (SCHD). METHODS We will search the following databases for relevant potential studies in Cochrane Library, MEDLINE, EMBASE, Web of Science, Google Scholar, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. We will search all literature sources from inception to the present without limitations of language and publication status. We will only consider randomized controlled trials on exploring the efficacy and safety of ticagrelor for the treatment of SCHD. Investigators will separately examine studies, collect data and appraise study quality. Data synthesis and analysis will be performed using RevMan 5.3 software. RESULTS This study will summarize high quality synthesis of present evidence of ticagrelor for the treatment of SCHD. CONCLUSION The findings of this study will provide evidence to appraise whether ticagrelor is effective for the treatment of patients with SCHD. OSF REGISTRATION NUMBER:: osf.io/fq69u.
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Gustafson C, Gower MN, Williams AK, Pauley E, Weck KE, Lee CR, Stouffer GA. Effect of Gender on Clinical Outcomes in Patients Receiving CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 13:554-556. [PMID: 32938199 DOI: 10.1161/circgen.120.003023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chelsea Gustafson
- Division of Cardiology (C.G., E.P., G.A.S.), UNC School of Medicine, Chapel Hill
| | - Megan N Gower
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill (M.N.G., A.K.W., C.R.L.)
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill (M.N.G., A.K.W., C.R.L.)
| | - Eric Pauley
- Division of Cardiology (C.G., E.P., G.A.S.), UNC School of Medicine, Chapel Hill
| | - Karen E Weck
- Department of Pathology and Laboratory Medicine (K.E.W.), UNC School of Medicine, Chapel Hill
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, Chapel Hill (M.N.G., A.K.W., C.R.L.).,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill (C.R.L., G.A.S.)
| | - George A Stouffer
- Division of Cardiology (C.G., E.P., G.A.S.), UNC School of Medicine, Chapel Hill.,UNC McAllister Heart Institute, University of North Carolina at Chapel Hill (C.R.L., G.A.S.)
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Schreuder MM, Badal R, Boersma E, Kavousi M, Roos-Hesselink J, Versmissen J, Visser LE, Roeters van Lennep JE. Efficacy and Safety of High Potent P2Y 12 Inhibitors Prasugrel and Ticagrelor in Patients With Coronary Heart Disease Treated With Dual Antiplatelet Therapy: A Sex-Specific Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e014457. [PMID: 32063118 PMCID: PMC7070195 DOI: 10.1161/jaha.119.014457] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Sex differences in efficacy and safety of dual antiplatelet therapy remain uncertain because of the underrepresentation of women in cardiovascular trials. The aim of this study was to perform a sex‐specific analysis of the pooled efficacy and safety data of clinical trials comparing a high potent P2Y12 inhibitor+aspirin with clopidogrel+aspirin in patients with acute coronary syndrome. Methods and Results A systematic literature search was performed. Randomized clinical trials that compared patients following percutaneous coronary intervention/acute coronary syndrome who were taking high potent P2Y12 inhibitors+aspirin versus clopidogrel+aspirin were selected. Random effects estimates were calculated and relative risks with 95% CIs on efficacy and safety end points were determined per sex. We included 6 randomized clinical trials comparing prasugrel/ticagrelor versus clopidogrel in 43 990 patients (13 030 women), with a median follow‐up time of 1.06 years. Women and men had similar relative risk (RR) reduction for major cardiovascular events (women: RR, 0.89 [95% CI, 0.80–1.00; men: RR, 0.84 [95% CI, 0.79–0.91) (P for interaction=0.39). Regarding safety, women and men had similar risk of major bleeding by high‐potency dual antiplatelet therapy (RR, 1.18 [95% CI, 0.98–1.41] versus RR, 1.03 [95% CI, 0.93–1.14]) (P for interaction=0.20). Conclusions The small and statistically insignificant difference in efficacy and safety estimates of high‐potency dual antiplatelet therapy between women and men following percutaneous coronary intervention/acute coronary syndrome do not justify differential dual antiplatelet therapy treatment for both sexes.
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Affiliation(s)
- Michelle M Schreuder
- Department of Internal Medicine Erasmus Medical Centre Rotterdam The Netherlands
| | - Ricardo Badal
- Department of Internal Medicine Erasmus Medical Centre Rotterdam The Netherlands
| | - Eric Boersma
- Department of Epidemiology Erasmus Medical Centre Rotterdam The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology Erasmus Medical Centre Rotterdam The Netherlands
| | | | - Jorie Versmissen
- Department of Internal Medicine Erasmus Medical Centre Rotterdam The Netherlands
| | - Loes E Visser
- Department of Epidemiology Erasmus Medical Centre Rotterdam The Netherlands
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