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Zhang X, Jing J, Zhao X, Liu L, Wang A, Pan Y, Wang D, Johnston SC, Wang Y, Wang Y, Meng X. No rebound effect after a course of clopidogrel in patients with acute TIA or minor stroke. Neurol Res 2022; 44:957-963. [PMID: 35695332 DOI: 10.1080/01616412.2022.2075660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies demonstrated that discontinuation of clopidogrel in patients after ACS was associated with a rebound increase in risk of recurrent events. In this study, we aimed to investigate the rebound effect after discontinuation of clopidogrel therapy in patients with TIA or stroke. METHODS All patients with minor stroke or TIA were recruited from the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Patients were divided into two groups: patients who discontinued clopidogrel and switched to aspirin therapy (Clopidogrel Discontinuation Group) and patients who continued one mono-antiplatelet therapy (non-Clopidogrel Discontinuation Group) during 90-180 days. The outcomes included risks of recurrent ischemic stroke, recurrent TIA, and composite events during 90-180 days. The prevalence of each outcome was compared between two groups for every 30 days. Further subgroup analysis was conducted in patients with and without CYP2C19 loss-of-function alleles. RESULTS Among the 3456 patients included, a total of 10 patients in the Clopidogrel Discontinuation Group and 11 patients in the non-Clopidogrel Discontinuation Group presented ischemic stroke recurrence during the 90-180-day period. The inter-group comparisons were not significant in each 30 days. Similar results were found for recurrent stroke, recurrent TIA, and composite events in these two groups, which were also found in CYP2C19 subgroup analysis. CONCLUSIONS No rebound increase in the risk of ischemic stroke and composite events was found during the 90 days after discontinuation of clopidogrel therapy in patients with TIA or minor stroke in the CHANCE trial. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00979589.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Az, USA
| | | | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Đukanović N, Obradović S, Zdravković M, Đurašević S, Stojković M, Tosti T, Jasnić N, Đorđević J, Todorović Z. Lipids and Antiplatelet Therapy: Important Considerations and Future Perspectives. Int J Mol Sci 2021; 22:ijms22063180. [PMID: 33804754 PMCID: PMC8003871 DOI: 10.3390/ijms22063180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/15/2023] Open
Abstract
Lipids play an essential role in platelet functions. It is known that polyunsaturated fatty acids play a role in increasing platelet reactivity and that the prothrombotic phenotype plays a crucial role in the occurrence of major adverse cardiovascular events. The ongoing increase in cardiovascular diseases’ incidence emphasizes the importance of research linking lipids and platelet function. In particular, the rebound phenomenon that accompanies discontinuation of clopidogrel in patients receiving dual antiplatelet therapy has been associated with changes in the lipid profile. Our many years of research underline the importance of reduced HDL values for the risk of such a rebound effect and the occurrence of thromboembolic events. Lipids are otherwise a heterogeneous group of molecules, and their signaling molecules are not deposited but formed “on-demand” in the cell. On the other hand, exosomes transmit lipid signals between cells, and the profile of such changes can be monitored by lipidomics. Changes in the lipid profile are organ-specific and may indicate new drug action targets.
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Affiliation(s)
- Nina Đukanović
- High Medical School Milutin Milanković, Crnotravska 27, 11000 Belgrade, Serbia;
| | - Slobodan Obradović
- Clinic of Emergency Medicine, Military Medical Academy, University of Defence, Crnotravska 27, 11000 Belgrade, Serbia;
- Medical Faculty of the Military Medical Academy, University of Defence, Crnotravska 27, 11000 Belgrade, Serbia
| | - Marija Zdravković
- Dr Subotića 8, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (M.S.)
- Dr Žorža Matea bb, University Medical Centre “Bežanijska kosa”, 11070 Belgrade, Serbia
| | - Siniša Đurašević
- Faculty of Biology, University of Belgrade, Studentski trg 3, 11000 Belgrade, Serbia; (S.Ð.); (N.J.); (J.Ð.)
| | - Maja Stojković
- Dr Subotića 8, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (M.S.)
| | - Tomislav Tosti
- Faculty of Chemistry, University of Belgrade, Studentski trg 12-16, 11000 Belgrade, Serbia;
| | - Nebojša Jasnić
- Faculty of Biology, University of Belgrade, Studentski trg 3, 11000 Belgrade, Serbia; (S.Ð.); (N.J.); (J.Ð.)
| | - Jelena Đorđević
- Faculty of Biology, University of Belgrade, Studentski trg 3, 11000 Belgrade, Serbia; (S.Ð.); (N.J.); (J.Ð.)
| | - Zoran Todorović
- Dr Subotića 8, School of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (M.S.)
- Correspondence: ; Tel.: +381-63-8827076
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Piccolo R, Feres F, Abizaid A, Gilard M, Morice MC, Hong MK, Kim HS, Colombo A, Bhatt DL, Palmerini T, Stone GW, Windecker S, Valgimigli M. Risk of Early Adverse Events After Clopidogrel Discontinuation in Patients Undergoing Short-Term Dual Antiplatelet Therapy: An Individual Participant Data Analysis. JACC Cardiovasc Interv 2018; 10:1621-1630. [PMID: 28838471 DOI: 10.1016/j.jcin.2017.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The study sought to evaluate the presence of a clinically relevant rebound phenomenon after dual antiplatelet therapy (DAPT) discontinuation in randomized trials. BACKGROUND It is currently unknown whether clopidogrel discontinuation after short-term DAPT is associated with an early hazard of ischemic events. METHODS The authors performed an individual participant data analysis and aggregate meta-analysis. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as the composite of cardiac death, myocardial infarction (MI), or stroke. RESULTS The study included 11,473 PCI patients with individual participant data from 6 randomized trials comparing short-term DAPT (3 or 6 months) versus long-term DAPT (12 months or more). During the first 90 days following clopidogrel discontinuation, there was no significant increase in the risk of MACCE between patients randomized to short-term DAPT compared with long-term DAPT (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 0.71 to 1.98; p = 0.52; absolute risk difference 0.10%; 95% CI: -0.16% to 0.36%). The risk of MI or stent thrombosis was similar among patients randomized to short-term DAPT versus long-term DAPT (HR: 0.93; 95% CI: 0.46 to 1.90; p = 0.85). In the aggregate data meta-analysis of 11 trials including 38,919 patients, a higher risk of early MACCE was observed after long-term (≥12 months) DAPT duration (HR: 2.28; 95% CI: 1.69 to 3.09; p < 0.001) but not short-term (<12 months) DAPT duration (HR: 1.08; 95% CI: 0.67 to 1.74; p for interaction = 0.036). CONCLUSIONS Among patients undergoing PCI with predominantly new-generation DES, discontinuation of clopidogrel after 3 or 6 months DAPT duration was not associated with an early increase in adverse clinical events. An early increase in MACCE was observed after long-term (≥12 months) DAPT exposure.
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Affiliation(s)
- Raffaele Piccolo
- Department of Cardiology, University Hospital of Bern, University of Bern, Switzerland
| | - Fausto Feres
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | | | - Martine Gilard
- Department of Cardiology, CHU de la Cavale Blanche, Brest, France
| | | | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Tullio Palmerini
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Stephan Windecker
- Department of Cardiology, University Hospital of Bern, University of Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, University Hospital of Bern, University of Bern, Switzerland.
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Olechowski B, Ashby A, Mariathas M, Khanna V, Mahmoudi M, Curzen N. Is arachidonic acid stimulation really a test for the response to aspirin? Time to think again? Expert Rev Cardiovasc Ther 2016; 15:35-46. [DOI: 10.1080/14779072.2017.1266255] [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] [Indexed: 12/26/2022]
Affiliation(s)
- Bartosz Olechowski
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Ashby
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Mariathas
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vikram Khanna
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Djukanovic N, Todorovic Z, Zamaklar-Trifunovic D, Protic D, Dzudovic B, Ostojic M, Obradovic S. Sustained increase in platelet aggregation after the cessation of clopidogrel. Clin Exp Pharmacol Physiol 2015; 43:161-5. [PMID: 26515635 DOI: 10.1111/1440-1681.12512] [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] [Received: 06/10/2015] [Revised: 10/18/2015] [Accepted: 10/25/2015] [Indexed: 11/29/2022]
Abstract
This study shows that the abrupt cessation of one-year clopidogrel treatment was not associated with thrombotic events in a prospective, multicentre study that enrolled 200 patients subjected to coronary stent implantation and treated with aspirin + clopidogrel 1 year after the stent placement. The aim of the study was to investigate the causes of a sustained increase of platelet aggregability, considering that the values of platelet aggregation stimulated with ADP + PGE1 (ADPHS values) significantly increased 10-90 days after the cessation of clopidogrel. Values of platelet aggregation induced by thrombin receptor activating peptide (TRAP values) and arachidonic acid (ASPI values) were divided into quartiles on the basis of ADPHS values 10 days after stopping clopidogrel (ADPHS10 ). There was a significant difference between TRAP values divided into quartiles according to ADPHS10 , 10, 45 and 90 days after stopping clopidogrel (P < 0.001, all), and ASPI values across the same quartiles 10 and 45 days after the cessation of clopidogrel (P = 0.028 and 0.003). The results of the study indicate that patients with early pronounced rebound phenomena to clopidogrel termination have a long-term (at least 90 days) increased platelet aggregation to other agonists such as thrombin-related activated protein and arachidonic acid, suggesting the complex mutual relationship of various factors/agonists influencing the function of platelets.
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Affiliation(s)
| | - Zoran Todorovic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Zamaklar-Trifunovic
- Department of Cardiology, Institute for Cardiovascular Diseases, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Dragana Protic
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Boris Dzudovic
- Clinic of Emergency Medicine, Military Medical Academy, University of Belgrade, Belgrade, Serbia
| | - Miodrag Ostojic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Obradovic
- Clinic of Emergency Medicine, Military Medical Academy, University of Belgrade, Belgrade, Serbia
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Ford I. Coming safely to a stop: a review of platelet activity after cessation of antiplatelet drugs. Ther Adv Drug Saf 2015; 6:141-50. [PMID: 26301068 PMCID: PMC4530348 DOI: 10.1177/2042098615588085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The platelet P2Y12 antagonists are widely used, usually in combination with aspirin, to prevent atherothrombotic events in patients with acute coronary syndromes during percutaneous coronary intervention and after placement of arterial stents. Inhibition by clopidogrel or prasugrel lasts for the lifetime of the affected platelets and platelet haemostatic function gradually recovers after stopping the drug, as new unaffected platelets are formed. The optimal durations for dual antiplatelet therapy are prescribed by clinical guidelines. Continuation beyond the recommended duration is associated with an increased mortality, mainly associated with major bleeding. Fear of a 'rebound' of prothrombotic platelet activity on stopping the drug has provoked much discussion and many studies. However, review of the available literature reveals no evidence for production of hyper-reactive platelets after cessation of clopidogrel in patients who are stable. Any increase in acute coronary and other vascular events after stopping seems most likely therefore to be due to premature discontinuation or disruption of treatment while thrombotic risk is still high. No difference in rebound was found with the newer P2Y12 inhibitors, although ticagrelor and prasugrel are more potent platelet inhibitors than clopidogrel. Recent randomized controlled trials confirm it is safe to stop the thienopyridine and continue with aspirin alone in most patients after the duration of treatment recommended by the guidelines. Decisions on when to stop therapy in individuals, however, remain challenging and there is a growing rationale for platelet testing to assist clinical judgement in certain situations such as patients stopping dual antiplatelet therapy before surgery or in individuals at highest bleeding or thrombotic risk.
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Affiliation(s)
- Isobel Ford
- Division of Applied Medicine, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Scotland, AB25 2ZD, UK
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Obradovic S, Djukanovic N, Todorovic Z, Markovic I, Zamaklar-Trifunovic D, Protic D, Ostojic M. Men with lower HDL cholesterol levels have significant increment of soluble CD40 ligand and high-sensitivity CRP levels following the cessation of long-term clopidogrel therapy. J Atheroscler Thromb 2014; 22:284-92. [PMID: 25273829 DOI: 10.5551/jat.26765] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM The aim of this study was to examine whether the termination of long-term clopidogrel therapy results in a proinflammatory state and whether lipid parameters influence the inflammatory response after stopping the drug. METHODS A prospective, multicenter study was conducted among 200 patients with implanted coronary stents who received dual antiplatelet therapy for one year, without ischemic or bleeding events. According to the guidelines, clopidogrel was discontinued after one year. In all patients, the high-sensitivity C-reactive protein (hsCRP), soluble CD40 ligand (sCD40L) and lipid [total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C)] levels were measured twice: on the day of cessation of clopidogrel and 45 days after the termination of clopidogrel treatment. RESULTS In men (n=151), the sCD40L serum levels were significantly higher 45 days after the discontinuation of clopidogrel (p=0.007), while the hsCRP levels were not significantly different (p=0.407). Furthermore, when analyzed across the HDL-C quartiles, the hsCRP and sCD40L values were found to be associated with the levels of HDL-C after the discontinuation of clopidogrel in men. In addition, the men in the first HDL-C quartile exhibited the most pronounced increase in the sCD40L levels (p=0.001) and had significantly higher hsCRP levels (p=0.001) compared to the subjects in the other quartiles. Other lipid parameters did not show any associations with the sCD40L or hsCRP levels. CONCLUSIONS The discontinuation of clopidogrel is associated with higher increments in the sCD40L level, and a pronounced proinflammatory response is associated with a lower HDL-C concentration.
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Affiliation(s)
- Slobodan Obradovic
- Clinic of Emergency Medicine, Military Medical Academy, Medical Faculty, University of Defense
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Lordkipanidzé M, Diodati JG, Schampaert E, Palisaitis DA, Pharand C. Evidence of platelet sensitization to ADP following discontinuation of clopidogrel therapy in patients with stable coronary artery disease. Platelets 2014; 26:545-51. [PMID: 25167467 DOI: 10.3109/09537104.2014.951318] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Epidemiological studies have linked clopidogrel discontinuation with an increased incidence of ischemic events. This has led to the hypothesis that clopidogrel discontinuation may result in a pharmacological rebound. We evaluated the impact of clopidogrel discontinuation on platelet function. Platelet aggregation was measured by light transmission aggregometry (LTA) in response to adenosine diphosphate (ADP) 0.5, 1, 1.5, 2.5, 5 and 10 µM and by VerifyNow® P2Y12, in 37 clinically stable coronary artery disease (CAD) patients scheduled to discontinue clopidogrel treatment, and 37 clinically stable CAD patients not taking clopidogrel. Platelet function was assessed the day before clopidogrel cessation and 1, 3, 7, 14, 21 and 28 days after. Clopidogrel had been initiated a median of 555 days (ranging from 200 to 2280 days) before the treating cardiologist recommended its discontinuation. All participants were taking aspirin, most commonly 80 mg daily although a minority was prescribed 325 mg daily. Following clopidogrel discontinuation, VerifyNow® P2Y12 did not detect any rebound platelet activity, but ADP-induced LTA showed platelet sensitization to ADP, particularly at low ADP levels. Increased platelet activity was detectable seven days after clopidogrel cessation and remained higher than in controls 28 days after discontinuation. No clinical event occurred in any of the participants during the 28 days following clopidogrel cessation. In conclusion, platelet sensitization to ADP as a consequence of chronic clopidogrel administration may partially explain the recrudescence of ischemic events following clopidogrel discontinuation in otherwise stable coronary artery patients.
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