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Lee Y, Shin JH, Seo SM, Choi IJ, Lee JY, Lee JW, Park MW, Kang TS, Choi WG, Jeon KH, Lim HS, Joo HJ, Rhee SJ, Seo JB, Park MS, Park SH, Lim YH. Influence of early dose reduction of ticagrelor on clinical outcomes following percutaneous coronary intervention for complex lesions. Sci Rep 2023; 13:15481. [PMID: 37726368 PMCID: PMC10509174 DOI: 10.1038/s41598-023-42655-4] [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: 02/07/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023] Open
Abstract
Ticagrelor-based dual antiplatelet therapy (DAPT) provides potent antiplatelet inhibition but may increase the bleeding risk in Asian populations. We investigated the influence of early ticagrelor dose reduction (120 mg) on clinical outcomes in Korean patients undergoing percutaneous coronary intervention (PCI). A multicenter prospective clinical cohort study was conducted with patients who received standard-dose ticagrelor-based DAPT (180 mg) after PCI for complex lesions. Major adverse cardiovascular event (MACE: a composite of cardiovascular death, myocardial infarction, stroke, and repeat revascularization), bleeding, and net adverse clinical events (NACE: a composite of MACE and bleeding) were assessed. Among the 772 patients on standard-dose ticagrelor-based DAPT, 115 (14.8%) switched to low-dose ticagrelor-based DAPT (120 mg) within 6 months. Common reasons for the regimen changes were switching as planned (38.8%), dyspnea (25.5%), and bleeding (23.6%). A multivariable Cox proportional hazard model (CPH) showed that the risks of MACE, bleeding, and NACE were not different between the low-dose and standard-dose groups throughout the entire follow-up period and the period beyond 6 months post-PCI. Time-varying multivariable CPH models of the ticagrelor dose reduction yielded similar results. A reduction of the ticagrelor dose within 6 months after PCI is feasible and safe even in patients with complex lesions harboring a high ischemic event risk.
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Affiliation(s)
- Yonggu Lee
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Jeong-Hun Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea
| | - Suk Min Seo
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jong-Young Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jun-Won Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Mahn-Won Park
- Division of Cardiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Tae Soo Kang
- Division of Cardiology, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Woong Gil Choi
- Department of Internal Medicine, College of Medicine, Chungbuk National University Hospital, Chungbuk National University, Cheongju, 28644, Republic of Korea
| | - Ki-Hyun Jeon
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hong-Seok Lim
- Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyung Joon Joo
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sang Jae Rhee
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Jae-Bin Seo
- Division of Cardiology, Department of Internal Medicine, Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myung Soo Park
- Division of Cardiology, Dongtan Sacred Heart Hospital, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
| | - Sang-Ho Park
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, 31, Suncheonhyang 6-gil, Dongnam-gu, Cheonan, 31151, Republic of Korea.
| | - Young-Hyo Lim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, 222 Wangsimni-ro, Sungdong-gu, Seoul, 04763, Republic of Korea.
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Liu L, Xu L, Guo N, Yang Y, Liu X, Qi T, Liang F. Ticagrelor is related to nuisance bleeding after flow diversion of unruptured intracranial aneurysms. Neurosurg Rev 2023; 46:134. [PMID: 37269331 DOI: 10.1007/s10143-023-02043-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Abstract
Nuisance bleeding (NB) without urgent medical attention is rarely characterized despite its frequent occurrence in patients with cerebral aneurysms undergoing flow diversion (FD) who are maintained on dual antiplatelet therapy (DAPT). This study explored the risk factors for NB. Patients with unruptured cerebral aneurysms who underwent intervention using FD (July 2018 to May 2022) and had follow-up data were enrolled. Patient demographics, clinical characteristics, aneurysm features and follow-up data were analysed. Bleeding complications were classified as NB, internal bleeding and alarming bleeding. NB was characterized by easy bruising, bleeding from small cuts and nonfatal petechiae and ecchymosis. Univariate and multivariate logistic regression analyses were performed to determine risk factors for NB. This study assessed 121 patients. Of these, 52 (43.0%) patients had NB. Compared with the non-bleeding group, the NB group had more females (82.7% vs. 56.5%; p = 0.003), lower smoking rate (7.7% vs. 23.2%; p = 0.027) and smaller aneurysms (6.65 mm [4.60-9.60 mm] vs. 8.82 mm [5.65-15.65 mm]; p = 0.007) and had more patients maintained on ticagrelor-containing DAPT regimen (90.4% vs. 66.7%; p = 0.002). Multivariate logistic regression revealed that ticagrelor-containing DAPT regimen (odds ratio, 3.91; 95% confidence interval, 1.29-11.87; p = 0.016) was associated with NB. These results suggest that NB is a common bleeding complaint in patients on DAPT. In patients undergoing FD, DAPT with ticagrelor was the only independent risk factor for NB.
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Affiliation(s)
- Linfeng Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Lin Xu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Xinman Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Feng Liang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China.
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Hu X, Zhao W, Zhang Q, Hu H, Luo S. Efficacy and Safety of Aspirin Combined with Low-Dose P2Y12 Receptor Antagonists in East Asian Patients Undergoing PCI. Int Heart J 2021; 62:742-751. [PMID: 34234075 DOI: 10.1536/ihj.20-772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Previous studies have indicated that low-dose new generation of P2Y12 receptor antagonists may be more suitable compared with clopidogrel at a standard dose for the dual antiplatelet therapy (DAPT) for East Asian patients receiving percutaneous coronary intervention (PCI). However, there remains no consensus in clinical practice. Thus, in this study, we aimed to determine the efficacy and safety of low-dose P2Y12 receptor antagonists, compared to clopidogrel at a standard dose, in DAPT in East Asian patients after PCI. We systematically searched literatures for randomized controlled trials (RCT) comparing low-dose P2Y12 receptor antagonists with standard-dose clopidogrel for the treatment of East Asian patients undergoing PCI. The endpoints of efficacy include major adverse cardiac events (MACEs), all-cause mortality, and the number of target vessel revascularization. The indicators of safety include major and minor bleeding events. Heterogeneity was evaluated by I2 statistic test. Begg's and Egger's tests were used to evaluate publication bias. In total, 2,747 subjects from 8 RCT studies were included. Low-dose new P2Y12 receptor antagonists, that is, ticagrelor or prasugrel, showed significantly lower incidence of MACEs, as compared with standard-dose clopidogrel, in the East Asian patients who are in DAPT after undergoing PCI. Further, no difference was noted for the risk of major and minor bleeding events. In East Asian patients undergoing PCI and receiving DAPT, the use of low-dose P2Y12 receptor antagonists, ticagrelor or prasugrel, has been determined to be superior than clopidogrel at standard dose; this has been evidenced by a lower incidence of MACEs without increasing the risk of bleeding.
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Affiliation(s)
- Xiankang Hu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University
| | - Weibo Zhao
- Department of Endocrinology, Diabetes Center of People's Liberation Army, Strategic Support Force Medical Center
| | - Qiongyue Zhang
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University
| | - Houyuan Hu
- Department of Cardiology, Southwest Hospital, Third Military Medical University (Army Medical University)
| | - Suxin Luo
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University
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Xenogiannis I, Varlamos C, Benetou DR, Alexopoulos D. Antithrombotic Therapy in Chronic Total Occlusion Interventions. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Chronic total occlusion (CTO) recanalization is among the most complex subsets of coronary interventions. Hence, optimum peri- and post-procedural anticoagulation and antiplatelet therapy is key for the achievement of successful revascularization and reduction of major adverse cardiovascular outcomes in patients undergoing CTO percutaneous coronary intervention (PCI). Unfractionated heparin is still considered the gold standard anticoagulant because its action can be reversed by protamine administration, with bivalirudin being reserved mainly for patients with heparin-induced thrombocytopenia. However, small studies comparing unfractionated heparin with bivalirudin in CTO interventions have shown similar outcomes. Glycoprotein IIb/IIIa inhibitors should, in general, be avoided. Aspirin in combination with clopidogrel for 6–12 months is the standard post CTO PCI dual antiplatelet regimen. For the most complex cases, clopidogrel can be substituted by a more potent P2Y12 inhibitor, namely ticagrelor or prasugrel.
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Affiliation(s)
- Iosif Xenogiannis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Adamski P, Ostrowska M, Navarese EP, Kubica J. Pharmacodynamic and clinical efficacy of reduced ticagrelor maintenance doses in patients with coronary artery disease. Curr Med Res Opin 2021; 37:195-206. [PMID: 33211543 DOI: 10.1080/03007995.2020.1854207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE An increasing body of data indicates that a reduction of ticagrelor maintenance dose (MD) in stabilized patients might improve ticagrelor's safety profile and adherence to the treatment. The aim of this review was to discuss the rationale and summarize the current pharmacodynamic and clinical outcomes-based evidence from reduced MD of ticagrelor in patients with coronary artery disease (CAD). METHODS A narrative systematic review based on a literature search using the PubMed database from its inception through to June 2020. A search strategy included a combination of relevant search terms regarding ticagrelor reduced MD. The pre-determined inclusion criteria were: (1) randomized or observational trials; (2) presentation of clinical or pharmacodynamic results; (3) evaluation of any ticagrelor MD below 90 mg BID in patients with CAD. RESULTS Studies evaluating the following ticagrelor reduced MD have been identified: 90 mg QD, 60 mg BID, 60 mg QD, 45 mg BID, 22.5 mg BID. Majority of trials assessing doses <60 mg BID were performed in Asian patients only. Antiplatelet effect of ticagrelor in CAD decreases with the dose, however even reduced MDs provide sufficient platelet inhibition, which is greater than in clopidogrel-treated patients. De-escalation of ticagrelor dose shows a propensity towards a reduced rate of bleeding and non-bleeding adverse events. CONCLUSIONS Ticagrelor doses below 90 mg BID generally show an acceptable profile of platelet inhibition. The number of studies reporting clinical outcomes in CAD patients receiving reduced MD of ticagrelor are limited, however available results indicate that in a stable setting this strategy offers improved safety with preserved efficacy in the prevention of thrombotic events.
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Affiliation(s)
- Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano Pio Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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