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Kayani WT, Khan MR, Deshotels MR, Jneid H. Challenges and Controversies in the Management of ACS in Elderly Patients. Curr Cardiol Rep 2020; 22:51. [PMID: 32500287 DOI: 10.1007/s11886-020-01298-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Elderly patients presenting with acute coronary syndrome (ACS) represent a challenging patient population. A high index of suspicion is needed for their diagnosis, as they are less likely to present with typical anginal symptoms compared to their younger counterparts. RECENT FINDINGS Disrupted coronary plaques with superimposed thrombosis are the predominant pathophysiology of ACS; however, an increased proportion of calcified nodules is encountered in elderly patients. Emergent reperfusion and revascularization remain the mainstay treatment for ST-elevation myocardial infarction or cardiogenic shock. In elderly patients with NSTE-ACS, a routine invasive strategy is generally superior to an ischemia-guided strategy, and the safety of an early invasive strategy has also been recently demonstrated. When treating elderly ACS patients with antiplatelet and antithrombotic therapies, close attention to co-morbidities, frailty and the balance of ischemia-bleeding risk should be undertaken, and medication doses should be carefully adjusted. Overall, elderly patients with ACS remain undertreated with evidence-based therapies, experience worse outcomes, and represent an opportunity for enhancing and mitigating healthcare disparities.
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Affiliation(s)
- Waleed T Kayani
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Mahin R Khan
- Division of Cardiology, McLaren-Flint/Michigan State University, Flint, MI, USA
| | | | - Hani Jneid
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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2
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Alexopoulos D, Lianos I, Vlachakis P, Sfantou D, Dragona VM, Varlamos C. De-Escalation of Treatment With Oral P2Y12 Receptor Inhibitors: Current Status and Perspectives. J Cardiovasc Pharmacol Ther 2019; 24:304-314. [DOI: 10.1177/1074248418823724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panagiotis Vlachakis
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Danai Sfantou
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Vassiliki-Maria Dragona
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalambos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Cheema AN. Managing Clopidogrel Hypersensitivity without Interrupting Therapy: The Toronto Approach. Curr Vasc Pharmacol 2019; 17:119-122. [DOI: 10.2174/1389200219666180820114435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 11/22/2022]
Abstract
Clopidogrel remains a widely used antiplatelet agent for patients with established or high risk
of atherothrombotic disease, particularly those treated with coronary, carotid or peripheral endovascular
stenting. Clopidogrel hypersensitivity is an uncommon but well established adverse drug reaction presenting
a challenge for patient management. The clinical presentation ranges from focal or diffuse cutaneous
manifestations in most patients to angioedema in some and a systemic immune response in rare
cases. The treatment options include drug discontinuation with or without desensitization therapy,
switching to alternate ADP receptor antagonists or administration of oral steroids while continuing
clopidogrel in patients at high risk of adverse events with clopidogrel discontinuation. In this review the
author describes the phenomenon of clopidogrel hypersensitivity, various treatment strategies.
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Affiliation(s)
- Asim N. Cheema
- Division of Cardiology, Terrence Donnelly Heart Center, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada
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Watti H, Dahal K, Zabher HG, Katikaneni P, Modi K, Abdulbaki A. Comparison of prasugrel and ticagrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta-analysis of randomized and non-randomized studies. Int J Cardiol 2017; 249:66-72. [DOI: 10.1016/j.ijcard.2017.07.103] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 01/19/2023]
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Alexopoulos D, Xanthopoulou I, Moulias A, Lekakis J. Long-Term P2Y12-Receptor Antagonists in Post-Myocardial Infarction Patients. J Am Coll Cardiol 2016; 68:1223-1232. [DOI: 10.1016/j.jacc.2016.05.088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 04/28/2016] [Accepted: 05/03/2016] [Indexed: 11/28/2022]
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Affiliation(s)
- Christos Pappas
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
| | - John Lekakis
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
| | - Dimitrios Alexopoulos
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
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Franchi F, Faz GT, Rollini F, Park Y, Cho JR, Thano E, Hu J, Kureti M, Aggarwal N, Durairaj A, Been L, Zenni MM, Guzman LA, Suryadevara S, Antoun P, Bass TA, Angiolillo DJ. Pharmacodynamic Effects of Switching From Prasugrel to Ticagrelor. JACC Cardiovasc Interv 2016; 9:1089-98. [DOI: 10.1016/j.jcin.2016.02.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 02/26/2016] [Accepted: 02/26/2016] [Indexed: 02/03/2023]
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Alexopoulos D, Xanthopoulou I, Deftereos S, Hamilos M, Sitafidis G, Kanakakis I, Pentara I, Vavouranakis M, Davlouros P, Hahalis G, Goudevenos J. Contemporary antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: 1-year outcomes from the GReek AntiPlatElet (GRAPE) Registry. J Thromb Haemost 2016; 14:1146-54. [PMID: 26990959 DOI: 10.1111/jth.13316] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 02/10/2016] [Indexed: 11/30/2022]
Abstract
UNLABELLED Essentials The comparative efficacy and safety of antiplatelet agents in 'real life' is not clear. We recruited acute coronary syndrome patients receiving percutaneous coronary intervention. At 1-year follow-up, prasugrel offers better anti-ischemic protection than clopidogrel. Prasugrel and ticagrelor are accompanied by more frequent bleeding events. SUMMARY Background The comparative efficacy and safety of antiplatelet treatment outside randomized trials is not clear. Objectives To investigate long-term efficacy and safety in 'real-life' acute coronary syndrome (ACS) patients treated by percutaneous coronary intervention (PCI) with contemporary use of clopidogrel, prasugrel and ticagrelor. Methods In a prospective, observational, multicenter cohort study, 2047 patients were recruited into the GReek AntiPlatElet (GRAPE) Registry and were followed-up for 1 year for major adverse cardiovascular events (MACE, a composite of death, non-fatal myocardial infarction, urgent revascularization and stroke) and bleeding events (Bleeding Academic Research Consortium [BARC] classification). Results Exposure to clopidogrel, prasugrel and ticagrelor by PCI occurred in 959, 363 and 717 patients, respectively. After adjustment, the rate of MACE (primary outcome endpoint) was lower in prasugrel-treated patients (4.4%) than in clopidogrel-treated patients (10.1%) (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.30-0.91), although not significantly different between ticagrelor (6.8%) and clopidogrel groups (HR, 0.78; 95% CI, 0.54-1.12). Any type of BARC-classified bleeding (secondary outcome endpoint) was more frequent in prasugrel-treated patients (51.2%) than in clopidogrel-treated patients (37.6%) (HR, 1.61; 95% CI, 1.33-1.95) and more frequent in ticagrelor-treated patients (56.9%) than in clopidogrel-treated patients (HR, 1.81; 95% CI, 1.55-2.10). An adjusted comparison between prasugrel and ticagrelor-treated groups did not reveal differences in any outcome measure. After adjustment, the death rate was more reduced by novel agents in comparison with clopidogrel (2.9% vs. 6.2%). Conclusions In ACS/PCI patients, prasugrel offered better anti-ischemic protection than clopidogrel, whereas use of both novel agents is accompanied by more frequent bleeding events.
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Affiliation(s)
- D Alexopoulos
- Department of Cardiology, Patras University Hospital, Patras, Greece
| | - I Xanthopoulou
- Department of Cardiology, Patras University Hospital, Patras, Greece
| | - S Deftereos
- Department of Cardiology, Athens General Hospital 'G. Gennimatas', Athens, Greece
| | - M Hamilos
- Department of Cardiology, Iraklion University Hospital, Iraklion, Greece
| | - G Sitafidis
- Department of Cardiology, Larissa University Hospital, Larissa, Greece
| | - I Kanakakis
- Department of Clinical Therapeutics, 'Alexandra' University Hospital, Athens, Greece
| | - I Pentara
- Department of Cardiology, Patras University Hospital, Patras, Greece
| | - M Vavouranakis
- 1st University Department of Cardiology, Ippokration Hospital, Ioannina, Greece
| | - P Davlouros
- Department of Cardiology, Patras University Hospital, Patras, Greece
| | - G Hahalis
- Department of Cardiology, Patras University Hospital, Patras, Greece
| | - J Goudevenos
- Department of Cardiology, Ioannina University Hospital, Ioannina, Greece
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Campo G, Pavasini R, Malagù M, Mascetti S, Biscaglia S, Ceconi C, Papi A, Contoli M. Chronic obstructive pulmonary disease and ischemic heart disease comorbidity: overview of mechanisms and clinical management. Cardiovasc Drugs Ther 2016; 29:147-57. [PMID: 25645653 DOI: 10.1007/s10557-014-6569-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In the last few years, many studies focused their attention on the relationship between chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD), showing that these diseases are mutually influenced. Many different biological processes such as hypoxia, systemic inflammation, endothelial dysfunction, heightened platelet reactivity, arterial stiffness and right ventricle modification interact in the development of the COPD-IHD comorbidity, which therefore deserves special attention in early diagnosis and treatment. Patients with COPD-IHD comorbidity have a worst outcome, when compared to patients with only COPD or only IHD. These patients showed a significant increase on risk of adverse events and of hospital readmissions for recurrent myocardial infarction, heart failure, coronary revascularization, and acute exacerbation of COPD. Taken together, these complications determine a significant increase in mortality. In most cases death occurs for cardiovascular cause, soon after an acute exacerbation of COPD or a cardiovascular adverse event. Recent data regarding incidence, mechanisms and prognosis of this comorbidity, along with the development of new drugs and interventional approaches may improve the management and long-term outcome of COPD-IHD patients. The aim of this review is to describe the current knowledge on COPD-IHD comorbidity. Particularly, we focused our attention on underlying pathological mechanisms and on all treatment and strategies that may improve and optimize the clinical management of COPD-IHD patients.
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Affiliation(s)
- Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliera Universitaria S.Anna di Ferrara, Cona, FE, Italy,
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Xanthopoulou I, Davlouros P, Tsigkas G, Koutsogiannis N, Patsilinakos S, Deftereos S, Hahalis G, Alexopoulos D. Factors Affecting Platelet Reactivity 2 Hours After P2Y 12 Receptor Antagonist Loading in Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction – Impact of Pain-to-Loading Time –. Circ J 2016; 80:442-9. [DOI: 10.1253/circj.cj-15-0495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Pre-hospital ticagrelor in ST-segment elevation myocardial infarction: Ready for prime time? Int J Cardiol 2015; 194:41-3. [PMID: 26011263 DOI: 10.1016/j.ijcard.2015.05.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/26/2015] [Accepted: 05/09/2015] [Indexed: 11/21/2022]
Abstract
In ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) peri-procedural P2Y12 antagonism - although of great importance - is often suboptimal, even with the novel oral antiplatelet agents prasugrel and ticagrelor. The concept of pre-hospital ticagrelor loading, investigated in the recently published Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary Artery (ATLANTIC) trial, appears quite a promising strategy to optimize peri-procedural platelet inhibition and potentially clinical outcome. Implementation of such an approach when treating low risk STEMI patients in 'real life' practice might prove even more beneficial than expected from the ATLANTIC results, given the reported delays from first medical contact to primary PCI performance.
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Campo G, Pavasini R, Biscaglia S, Contoli M, Ceconi C. Overview of the pharmacological challenges facing physicians in the management of patients with concomitant cardiovascular disease and chronic obstructive pulmonary disease. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:205-11. [PMID: 27533997 DOI: 10.1093/ehjcvp/pvv019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/01/2015] [Indexed: 01/07/2023]
Abstract
Cardiovascular disease (CVD), including ischaemic heart disease (IHD) and heart failure (HF), and chronic obstructive pulmonary disease (COPD) are often concomitant because they share both risk factors (smoke) and pathological pathways (systemic inflammation). Cardiovascular disease and COPD association is increasing overtime. Several registries clearly showed a negative impact on the clinical outcome of the concomitant presence of CVD and COPD. Patients with CVD and COPD present an increased risk for myocardial infarction, HF, and hospital admission for acute exacerbation of COPD, with a negative impact on prognosis. To reduce the effect of this negative association, it is of paramount importance the pharmacological treatment with both cardiovascular and respiratory drugs, according to current guidelines. Nevertheless, several registries and studies showed that evidence-based drugs (both cardiovascular and respiratory) are often under administered in this subset of patients. In this overview, we summarize the available data regarding the use of cardiovascular drugs (antiplatelet agents, angiotensin converting enzyme inhibitors, β-blockers, and statins) in COPD patients, with or without concomitant IHD. Furthermore, we report advantages and disadvantages of respiratory drugs (β2 agonists, anti-cholinergics, and corticosteroids) administration in COPD patients with CVD.
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Affiliation(s)
- Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria S.Anna, Cona (FE), Italy LTTA Center, Ferrara, Italy
| | - Rita Pavasini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria S.Anna, Cona (FE), Italy
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria S.Anna, Cona (FE), Italy
| | - Marco Contoli
- Research Centre on Asthma and COPD, Section of Internal and Cardio-Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Claudio Ceconi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria S.Anna, Cona (FE), Italy LTTA Center, Ferrara, Italy
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Xanthopoulou I, Deftereos S, Sitafidis G, Kanakakis I, Hamilos M, Karayannis G, Angelidis C, Stavrou K, Vavuranakis M, Goudevenos JA, Stefanadis C, Alexopoulos D. In-hospital bleeding events in acute coronary syndrome patients undergoing percutaneous coronary intervention in the era of novel P2Y12 inhibitors: Insights from the GReek AntiPlatelet rEgistry–GRAPE. Int J Cardiol 2014; 174:160-2. [DOI: 10.1016/j.ijcard.2014.03.161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022]
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Alexopoulos D, Xanthopoulou I, Deftereos S, Sitafidis G, Kanakakis I, Hamilos M, Karayannis G, Angelidis C, Stavrou K, Vavuranakis M, Goudevenos JA, Stefanadis C. Bivalirudin Use and One-Month Outcome in the Context of Contemporary Antiplatelet Treatment: Insights from the Greek Antiplatelet Registry. Cardiovasc Ther 2014; 32:120-6. [DOI: 10.1111/1755-5922.12068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | | | - Spyridon Deftereos
- Department of Cardiology; Athens General Hospital “G. Gennimatas”; Athens Greece
| | - George Sitafidis
- Department of Cardiology; Larissa University Hospital; Larissa Greece
| | | | - Michalis Hamilos
- Department of Cardiology; Iraklion University Hospital; Iraklion Greece
| | - George Karayannis
- Department of Cardiology; Larissa University Hospital; Larissa Greece
| | - Christos Angelidis
- Department of Cardiology; Athens General Hospital “G. Gennimatas”; Athens Greece
| | - Katerina Stavrou
- Department of Cardiology; Patras University Hospital; Patras Greece
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Bauer T, Hamm C. Optimum Utilisation of Novel Antiplatelet Agents in Clinical Practice. Interv Cardiol 2014; 9:164-167. [PMID: 29588796 DOI: 10.15420/icr.2014.9.3.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Prasugrel and ticagrelor are two novel promising antiplatelet agents inhibiting the platelet activation via the adenosine diphosphate pathway. Both achieve a faster, more intense, and more consistent platelet inhibition than clopidogrel. Both novel antiplatelet agents have demonstrated superiority over clopidogrel in large, randomised controlled trials in patients with acute coronary syndrome (ACS). Prasugrel may be best suited for younger patients with planned percutaneous coronary intervention and large areas of myocardium at risk or diabetes mellitus who have a low risk of bleeding. The benefits of prasugrel relative to clopidogrel in ACS must be weighed against the increase in the risk of bleeding associated with its use. Ticagrelor may be the best option for patients with ACS without T elevations, elderly patients or patients managed conservatively. Vorapaxar, a new oral protease-activated-receptor 1 antagonist, may be a good option for secondary prevention in patients with stable atherosclerosis and no history of stroke.
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Affiliation(s)
- Timm Bauer
- Medical Clinic I, University of Giessen, Germany
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