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Hwang D, Kim HL, Koo BK, Rhee TM, Yang DW, Seo Y, Byun J, Kang J, Han JK, Park KW, Shin ES, Rha SW, Bae JW, Mamas MA, Cohen DJ, Lee TJ, Kim HS. Cost-Effectiveness of Clopidogrel vs Aspirin Monotherapy After Percutaneous Coronary Intervention: Results From the HOST-EXAM Study. JACC. ASIA 2023; 3:198-207. [PMID: 37181388 PMCID: PMC10167521 DOI: 10.1016/j.jacasi.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/25/2022] [Accepted: 12/06/2022] [Indexed: 05/16/2023]
Abstract
Background The HOST-EXAM (Harmonizing Optimal Strategy for Treatment of Coronary Artery Disease-Extended Antiplatelet Monotherapy) trial showed superior efficacy and safety of clopidogrel monotherapy compared with aspirin monotherapy during the chronic maintenance period after percutaneous coronary intervention (PCI). Objectives The goal of this study was to investigate the cost-effectiveness of clopidogrel monotherapy compared with that of aspirin monotherapy. Methods A Markov model was developed for patients in the stable phase after PCI. From the perspectives of the South Korean, UK, and U.S. health care systems, the lifetime health care costs and quality-adjusted life-years (QALYs) of each strategy were estimated. Transition probabilities were obtained from the HOST-EXAM trial, and health care costs and health-related utilities were obtained from data and literature for each country. Results From the perspective of the South Korean health care system, the base-case analysis showed that clopidogrel monotherapy was $3,192 higher in lifetime health care costs and 0.139 lower in QALYs compared with aspirin. This result was greatly influenced by the numerically but insignificantly higher cardiovascular mortality of clopidogrel compared with aspirin. In the analogous UK and U.S. models, clopidogrel monotherapy was projected to decrease health care costs by £1,122 and $8,920 per patient compared with aspirin monotherapy while reducing QALYs by 0.103 and 0.175, respectively. Conclusions Based on empirical data from the HOST-EXAM trial, clopidogrel monotherapy was projected to lead to reduced QALYs compared with aspirin during the chronic maintenance period after PCI. These results were affected by a numerically higher rate of cardiovascular mortality in clopidogrel monotherapy reported from the HOST-EXAM trial. (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis-Extended Antiplatelet Monotherapy [HOST-EXAM]; NCT02044250).
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Hea-Lim Kim
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Dong-Wook Yang
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
| | - Youngwon Seo
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Joonsoo Byun
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, Ulsan, South Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea
| | - Jang-Whan Bae
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk, South Korea
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York, USA
- St. Francis Hospital, Roslyn, New York, USA
| | - Tae-Jin Lee
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - HOST-EXAM Investigators
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, South Korea
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
- Department of Cardiology, Ulsan University Hospital, Ulsan, South Korea
- Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University College of Medicine, Chungbuk, South Korea
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
- Cardiovascular Research Foundation, New York, New York, USA
- St. Francis Hospital, Roslyn, New York, USA
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Meng LP, Wang P, Peng F. Acute coronary artery stent thrombosis caused by a spasm: A case report. World J Clin Cases 2022; 10:2923-2930. [PMID: 35434099 PMCID: PMC8968808 DOI: 10.12998/wjcc.v10.i9.2923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/25/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute stent thrombosis (AST) is a serious complication of percutaneous coronary intervention (PCI). The causes of AST include the use of stents of inappropriate diameters, multiple overlapping stents, or excessively long stents; incomplete stent expansion; poor stent adhesion; incomplete coverage of dissection; formation of thrombosis or intramural hematomas; vascular injury secondary to intraoperative mechanical manipulation; insufficient dose administration of postoperative antiplatelet medications; and resistance to antiplatelet drugs. Cases of AST secondary to coronary artery spasms are rare, with only a few reports in the literature.
CASE SUMMARY A 55-year-old man was admitted to the hospital with a chief complaint of back pain for 2 d. He was diagnosed with coronary heart disease and acute myocardial infarction (AMI) based on electrocardiography results and creatinine kinase myocardial band, troponin I, and troponin T levels. A 2.5 mm × 33.0 mm drug-eluting stent was inserted into the occluded portion of the right coronary artery. Aspirin, clopidogrel, and atorvastatin were started. Six days later, the patient developed AST after taking a bath in the morning. Repeat coronary angiography showed occlusion of the proximal stent, and intravascular ultrasound showed severe coronary artery spasms. The patient’s AST was thought to be caused by coronary artery spasms and treated with percutaneous transluminal coronary angioplasty. Postoperatively, he was administered diltiazem to inhibit coronary artery spasms and prevent future episodes of AST. He survived and reported no discomfort at the 2-mo follow-up after the operation and initiation of drug treatment.
CONCLUSION Coronary spasms can cause both AMI and AST. For patients who exhibit coronary spasms during PCI, diltiazem administration could reduce spasms and prevent future AST.
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Affiliation(s)
- Li-Ping Meng
- Department of Cardiology, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
| | - Ping Wang
- Department of Cardiology, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
| | - Fang Peng
- Department of Cardiology, Shaoxing People's Hospital, Shaoxing 312000, Zhejiang Province, China
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Tan BEX, Wong PY, Baibhav B, Thakkar S, Azhar AZ, Rao M, Cheung JW. Clopidogrel Versus Aspirin Monotherapy Following Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis. Curr Probl Cardiol 2022:101174. [PMID: 35341798 DOI: 10.1016/j.cpcardiol.2022.101174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/22/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Current guidelines recommend 6 to 12 months of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) followed by aspirin monotherapy indefinitely. We aimed to assess the efficacy and safety of clopidogrel versus aspirin in the post-PCI population after completing DAPT. METHODS We systematically searched five electronic databases to identify studies comparing clopidogrel with aspirin following completion of DAPT after PCI. We pooled outcomes for major adverse cardiac events (MACE), cardiac death, all-cause death, major bleeding, myocardial infarction (MI), and stroke. RESULTS We included five studies with 13,850 patients, of whom 5601 (40.4%) received clopidogrel. Mean follow-up was 12-36 months. All patients received drug-eluting stents. Duration of DAPT before antiplatelet monotherapy was 1-18 months. Clopidogrel was associated with reductions in MACE (Risk ratio [RR] 0.78, 95% confidence interval [CI] 0.66-0.92), any stroke (RR 0.51; 95% confidence interval [CI] 0.35-0.76), ischemic stroke (RR 0.55; 95% CI 0.32-0.94), and hemorrhagic stroke (RR 0.24; 95% CI 0.09-0.68) when compared with aspirin. Cardiac death (RR 0.87; 95% CI 0.53-1.41), all-cause death (RR 1.06; 95% CI 0.81-1.39), major bleeding (RR 0.74; 95% CI 0.43-1.29), MI (RR 1.01; 95% CI 0.64-1.60), repeat revascularization (RR 0.88; 95% CI 0.71-1.09), target vessel revascularization (RR 0.76; 95% CI 0.52-1.13), and stent thrombosis (RR 0.96; 95% CI 0.35-2.59) were not significantly different among groups. CONCLUSION Compared with aspirin, clopidogrel was associated with reductions in MACE and stroke (ischemic and hemorrhagic) following DAPT completion after PCI. There were no significant differences in mortality, major bleeding, MI, and repeat revascularization between groups.
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Affiliation(s)
- Bryan E-Xin Tan
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA.
| | - Pui Yen Wong
- Department of Internal Medicine, Sungai Buloh Hospital, Selangor, Malaysia
| | - Bipul Baibhav
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY, USA
| | | | | | - Mohan Rao
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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Nishino S, Sakuma M, Abe S, Toyoda S, Inoue T. Mechanism of Vascular Injury and Repair - Importance of Lesion Morphology. Circ J 2022; 86:975-976. [PMID: 35034928 DOI: 10.1253/circj.cj-21-1037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Setsu Nishino
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine
| | - Masashi Sakuma
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine
| | - Shichiro Abe
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine
| | - Teruo Inoue
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine.,Center for Advanced Medical Science Research, Dokkyo Medical University School of Medicine
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