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Alrabadi N, Aljarrah Q, Alzoubi O, Al-Jarrah H, Elayyan Y, Alnabulsi Z, Husein A, Alzoubi KH, Bakkar S, Aljanabi M, Zihlif M, Haddad R. Clinical recurrence and antiplatelet drug resistance among patients with lower limb ischemia. Medicine (Baltimore) 2024; 103:e36915. [PMID: 38215136 PMCID: PMC10783292 DOI: 10.1097/md.0000000000036915] [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: 10/13/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024] Open
Abstract
There is a high prevalence rate of peripheral artery disease worldwide, with estimated cases exceeding 200 million. Most patients are under-diagnosed and under-treated, and there is a lack of knowledge regarding the best therapeutic regimen and therapy duration, which leads to many cases of recurrence, complications, and amputations. This study aims to explore clinical recurrence, which was defined as the worsening of chronic peripheral artery disease requiring hospital admission, and its relationship with antiplatelet drug resistance among patients with lower limb ischemia. This cohort study includes both retrospective and prospective recruitment of patients with chronic lower limb ischemia. Platelet aggregation tests were offered to the patients. Between February 2018 and November 2020, 147 patients were recruited from King Abdullah University Hospital and followed up for at least 1 year. Platelet aggregation tests were done for 93 patients who agreed to participate in this part of the study. The prevalence of chronic lower limb ischemia was higher in young male patients who are current smokers with co-morbid diseases such as hypertension, diabetes mellitus, and/or dyslipidemia. There was a significant association only of clinical recurrence with younger age (P = .011) and with low platelets count in severe stages of the disease (P = .047). No significant association was found in terms of laboratory resistance. The clinical recurrence rates of chronic lower limb ischemia were higher in younger patients and among those with low platelet counts in the severe stages of the disease. Despite the laboratory responsiveness to anti-platelet therapy, we observed significant clinical resistance and increased recurrence rates.
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Affiliation(s)
- Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Qusai Aljarrah
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Osama Alzoubi
- Department of Medicine, Division of Rheumatology, the University of Illinois, Chicago, IL, USA
| | - Hussam Al-Jarrah
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Yasmin Elayyan
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Zaid Alnabulsi
- Department of Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Anas Husein
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Karem H. Alzoubi
- Department of Pharmacy Practice and Pharmacotherapeutics, University of Sharjah, Sharjah, United Arab Emirates
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Sohail Bakkar
- Department of General and Specialized Surgery, Faculty of Medicine, the Hashemite University, Zarqa, Jordan
| | - Mukhallad Aljanabi
- Department of Physiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Malik Zihlif
- Department of Pharmacology, School of Medicine, University of Jordan, Amman, Jordan
| | - Razan Haddad
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Jadara University, Irbid, Jordan
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Marcucci R, Berteotti M, Gragnano F, Galli M, Cavallari I, Renda G, Capranzano P, Santilli F, Capodanno D, Angiolillo DJ, Cirillo P, Calabrò P, Patti G, De Caterina R. Monitoring antiplatelet therapy: where are we now? J Cardiovasc Med (Hagerstown) 2022; 24:e24-e35. [PMID: 36729588 DOI: 10.2459/jcm.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Single antiplatelet therapy represents the cornerstone of thrombosis prevention in atherosclerotic cardiovascular disease. Dual antiplatelet therapy (DAPT), consisting of aspirin plus a P2Y12 inhibitor, is the standard of care for patients with acute coronary syndrome or undergoing both coronary and peripheral percutaneous interventions. Recent data suggest the efficacy of DAPT also after minor stroke. In this setting, a large body of evidence has documented that genetic and acquired patients' characteristics may affect the magnitude of platelet inhibition induced by antiplatelet agents. The implementation of tools allowing the identification and prediction of platelet inhibition has recently been shown to improve outcomes, leading to an optimal balance between antithrombotic efficacy and bleeding risk. We are therefore clearly moving towards tailored antiplatelet therapy. The aim of this paper is to summarize the available evidence on the evaluation of platelet inhibition in patients with coronary, peripheral, or cerebrovascular atherosclerosis. We will here focus on antiplatelet therapy based on both aspirin and P2Y12 inhibitors. In addition, we provide practical insights into the clinical settings in which it appears reasonable to implement antiplatelet therapy monitoring.
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Affiliation(s)
- Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Martina Berteotti
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Felice Gragnano
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome.,Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | | | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara
| | - Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Francesca Santilli
- Department of Medicine and Aging, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples
| | - Paolo Calabrò
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Giuseppe Patti
- Maggiore della Carità Hospital, University of Eastern Piedmont, Novara
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa.,Division of Cardiology, Azienda Ospedaliero-Universitaria Pisana, Pisa.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Pescara, Italy
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Markel KM, Avgerinos ED. Clopidogrel Resistance in Lower Extremity Arterial Endovascular Interventions. Curr Pharm Des 2019; 24:4554-4557. [PMID: 30621557 DOI: 10.2174/1381612825666190101111123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/18/2018] [Accepted: 12/26/2018] [Indexed: 01/03/2023]
Abstract
Antiplatelet pharmacotherapy for endovascular interventions has been widely adopted, with clopidogrel being one of the most common agents prescribed. A fraction of patients is resistant to clopidogrel resulting in decreased platelet inhibition despite adequate use. This finding is often termed high on-treatment platelet reactivity (HPR) and may lead to decreased patency in lower extremity arterial endovascular interventions. Current literature on HPR with lower extremity arterial endovascular interventions is limited to only a few studies. Resistance to clopidogrel is largely a result of CYP2C19 enzyme loss of function alleles. Several tests are available to measure clopidogrel resistance but light transmittance aggregometry remains the gold standard, yet direct genetic testing may be more reliable. One-year patency rates following lower extremity arterial endovascular interventions in patients with clopidogrel resistance (HPR) range between 35%-83% whereas those with the proper response to clopidogrel range between 73%-100%. Patients with decreased CYP2C19 activity show a significant decrease in one-year patency of endovascular femoropopliteal interventions (35% vs. 73%; p=0.006). Among patients tested for platelet function after in-stent thrombosis, up to 53% are resistant to clopidogrel. Lack of robust data limits our ability to predict patency in lower extremity arterial interventions for patients with HPR, but there is little doubt that longer patency seems to favor non-HPR patients. Large population, prospective trials are needed to guide our practice.
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Affiliation(s)
- Kyle M Markel
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
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Guirgis M, Thompson P, Jansen S. Review of aspirin and clopidogrel resistance in peripheral arterial disease. J Vasc Surg 2017; 66:1576-1586. [PMID: 28893489 DOI: 10.1016/j.jvs.2017.07.065] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/07/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Aspirin resistance (AR) and clopidogrel resistance (CR) are terms used to describe a reduction in the medication's efficacy in inhibiting platelet aggregation despite regular dosing. This review gives context to the clinical role and implications of antiplatelet resistance in peripheral arterial disease (PAD). METHODS A review of English-language literature on AR and CR in PAD involving human subjects using PubMed and MEDLINE databases was performed in April 2017. A total of 2075 patients in 22 relevant studies were identified. To give this issue context, a review of the larger, more established literature on antiplatelet resistance in coronary disease was undertaken, identifying significant research associating resistance to major adverse cardiovascular events (MACEs). RESULTS Studies in the coronary arterial disease literature have strongly associated antiplatelet resistance with increased MACE. Prevalence of AR or CR in coronary disease appears to be >55% for each in some studies. Meta-analyses of >50 studies revealed that AR and CR are significantly associated with MACE (relative risk of 2.09 and 2.8, respectively). This adds further weight to the literature reporting antiplatelet resistance as an independent predictor of and a threefold risk factor for major adverse cardiovascular events. The prevalence of resistance in PAD in this review was comparable to that in the coronary disease literature, with AR and CR prevalence up to 60% and 65%, respectively. There is evidence that the adverse effects of antiplatelet resistance are significant in PAD. In fact, research directly studying stent thrombosis populations with either coronary arterial disease or PAD revealed more significantly impaired platelet responsiveness to clopidogrel and aspirin in PAD compared with similar individuals with coronary disease. AR in PAD was found in studies to be a significant risk factor for iliofemoral stent reocclusion (P = .0093) and stroke in patients with symptomatic carotid disease (P = .018). CR was found to be a significant, independent risk factor in predicting ischemic outcomes in several recent PAD studies (P < .0001). Loss-of-function carriers of enzyme CYP2C19, important in clopidogrel metabolism, have a 30% greater risk of ischemic events (P < .001). Importantly, less antiplatelet drug resistance may be encountered with newer antiplatelet agents, including ticagrelor and prasugrel, because of reduced enzymatic polymorphisms. CONCLUSIONS The limited research addressing AR and CR in PAD suggests that further research is required to clarify the role of platelet assays and potential for individualized antiplatelet therapy.
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Affiliation(s)
- Mina Guirgis
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - Peter Thompson
- Harry Perkins Medical Research Institute, Perth, Western Australia, Australia; Department of Medicine and Population Health, University of Western Australia, Perth, Western Australia, Australia
| | - Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Harry Perkins Medical Research Institute, Perth, Western Australia, Australia; Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
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