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Nardin M, Verdoia M, Gioscia R, Negro F, De Luca G. Impact of renin angiotensin system inhibitors on homocysteine levels and platelets reactivity in patients on dual antiplatelet therapy. Nutr Metab Cardiovasc Dis 2021; 31:1276-1285. [PMID: 33549433 DOI: 10.1016/j.numecd.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Dual antiplatelet therapy (DAPT) and Renin-angiotensin system inhibitors (RASi) represent the cornerstone in the treatment of patients undergoing percutaneous coronary interventions (PCI), mainly after an acute ischemic event. However, high-on treatment residual platelet reactivity (HRPR), is not infrequent despite optimal medical treatment. Homocysteine (Hcy) is a metabolite of methionine catabolism linked to atherothrombosis. Recently, a potential crosstalk between RAS and Hcy has been suggested, potentially favouring platelet aggregation and cardiovascular disease.Therefore, we aimed to investigate the impact of RASi on Hcy levels and platelet aggregation in patients on DAPT after PCI. METHODS AND RESULTS Patients undergoing PCI on DAPT with ASA plus an ADP-antagonist (clopidogrel, ticagrelor or prasugrel), were included. RASi comprised angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). Aggregation tests were performed by Multiple Electrode Aggregometry. We included 1210 patients, of whom 862 (71.2%) were on treatment with RASi. Overall, DAPT composition was ASA+clopidogrel in 566 (46.8%) patients, ASA+ticagrelor in 428 (35.4%) and ASA+prasugrel in 216 (17.9%). Median values of Hcy were higher in RASi patients (p = 0.006), who displayed a higher percentage of Hcy above the median value (52.4% vs. 44.8%, p = 0.019, adjustedOR [95%CI] = 1.40 [1.04-1.88], p = 0.027). No differences in HRPR rate were found according to RASi use for ASPI test (3.6% vs. 3.3%, p = 0.88) and ADP test (25.6% vs. 24.3%,p = 0.62; adjustedOR [95%CI] = 1.23 [0.89-1.70], p = 0.220) and according to ADP-antagonist type. A direct linear relationship was observed between platelet reactivity and Hcy in both patients receiving RASi and untreated ones, with higher values of platelet aggregation being observed in patients with Hcy above the median, independently from RASi administration and DAPT strategy. CONCLUSION In patients on DAPT after PCI, RASi treatment did not emerge as an independent predictor of HRPR. However, the levels of Hcy were significantly elevated in patients on RASi and related to higher values of platelet reactivity, independently from the DAPT strategy.
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Affiliation(s)
- Matteo Nardin
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Department of Medicine, ASST "Spedali Civili", University of Brescia, Brescia, Italy
| | - Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Division of Cardiology, "Ospedale degli Infermi", Biella, Italy
| | - Rocco Gioscia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Li J, Wang Y, Li H, Zuo Z, Lin J, Wang A, Zhao X, Liu L, Wang Y. Homocysteine Level Predicts Response to Dual Antiplatelet in Women With Minor Stroke or Transient Ischemic Attack: Subanalysis of the CHANCE Trial. Arterioscler Thromb Vasc Biol 2020; 40:839-846. [PMID: 31941381 DOI: 10.1161/atvbaha.119.313741] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the relationship of homocysteine levels with the efficacy and safety of dual antiplatelet therapy in female and male patients. Approach and Results: The CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events) randomized patients with acute minor ischemic stroke or high-risk transient ischemic attack to clopidogrel plus aspirin or aspirin alone from October 1, 2009, to July 30, 2012, in China. A subgroup of 3044 consecutive patients with baseline homocysteine levels from 73 (64%) prespecified clinical sites was analyzed. Participants were grouped by sex. Primary outcome was stroke recurrence within 90 days. Secondary outcomes consisted of composite vascular events and independent living or death. Safety outcome was any bleeding. Cox proportional-hazards models were used to assess the interaction of homocysteine levels with randomized antiplatelet therapy on efficacy and safety outcomes. A significant interaction between homocysteine levels and the randomized antiplatelet therapies was found on recurrent stroke after adjustment for confounding factors in women (P=0.010) but not in men (P=0.595). Compared with aspirin alone, clopidogrel plus aspirin significantly reduced the risk of recurrent stroke in women without elevated homocysteine levels (adjusted hazard ratio, 0.459 [95% CI, 0.271-0.776]; P=0.004). Such benefit disappeared in female patients with increased homocysteine level. No significant interaction on functional outcome or bleeding rate was observed. CONCLUSIONS Homocysteine could be a potential biomarker to discriminate the effects of dual and single antiplatelet therapy in female patients with minor ischemic stroke or high-risk transient ischemic attack. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979589.
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Affiliation(s)
- Jiejie Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Hao Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health System, Charlottesville (Z.Z.)
| | - Jinxi Lin
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Center of Stroke, Beijing Institute for Brain Disorders, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang).,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China (J. Li, Yilong Wang., H.L., J. Lin, A.W., X.Z., L.L., Yongjun Wang)
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