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Yun JP, Kang J, Park KW, Park K, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Chae IH, Moon KW, Park HW, Won KB, Jeon DW, Han KR, Choi SW, Ryu JK, Jeong MH, Kim HS. Prasugrel-Based De-Escalation in Patients With Acute Coronary Syndrome According to Renal Function. JACC Asia 2023; 3:51-61. [PMID: 36873753 PMCID: PMC9982221 DOI: 10.1016/j.jacasi.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/22/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
Background Patients with coronary artery disease and impaired renal function are at higher risk for both bleeding and ischemic adverse events after percutaneous coronary intervention (PCI). Objectives This study assessed the efficacy and safety of a prasugrel-based de-escalation strategy in patients with impaired renal function. Methods We conducted a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS study. Patients with available estimated glomerular filtration rate (eGFR) (n = 2,311) were categorized into 3 groups. (high eGFR: >90 mL/min; intermediate eGFR: 60 to 90 mL/min; and low eGFR: <60 mL/min). The end points were bleeding outcomes (Bleeding Academic Research Consortium type 2 or higher), ischemic outcomes (cardiovascular death, myocardial infarction, stent thrombosis, repeated revascularization, and ischemic stroke), and net adverse clinical event (including any clinical event) at 1-year follow-up. Results Prasugrel de-escalation was beneficial regardless of baseline renal function (P for interaction = 0.508). The relative reduction in bleeding risk from prasugrel de-escalation was higher in the low eGFR group than in both the intermediate and high eGFR groups (relative reductions, respectively: 64% (HR: 0.36; 95% CI: 0.15-0.83) vs 50% (HR: 0.50; 95% CI: 0.28-0.90) and 52% (HR: 0.48; 95% CI: 0.21-1.13) (P for interaction = 0.646). Ischemic risk from prasgurel de-escalation was not significant in all eGFR groups (HR: 1.18 [95% CI: 0.47-2.98], HR: 0.95 [95% CI: 0.53-1.69], and HR: 0.61 [95% CI: 0.26-1.39]) (P for interaction = 0.119). Conclusions In patients with acute coronary syndrome receiving PCI, prasugrel dose de-escalation was beneficial regardless of the baseline renal function.
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Affiliation(s)
- Jun Pil Yun
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyungil Park
- Dong-A University Hospital, Busan, Republic of Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, Republic of Korea
| | - In-Ho Chae
- Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | | | - Hyun Woong Park
- Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Ki-Bum Won
- Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, South Korea
| | - Dong Woon Jeon
- National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Kyoo-Rok Han
- Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Si Wan Choi
- Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jae Kean Ryu
- Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Myung Ho Jeong
- Cheonnam University Hospital, Gwangju, Republic of Korea
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul, Republic of Korea
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Hwang D, Lim HS, Park KW, Shin WY, Kang J, Han JK, Yang HM, Kang HJ, Koo BK, Cho YK, Hong SJ, Kim S, Jo SH, Kim YH, Kim W, Lee SY, Oh SK, Kim DB, Kim HS. Durable polymer versus biodegradable polymer drug-eluting stents in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS trial. EUROINTERVENTION 2022; 18:e910-e919. [PMID: 36000257 PMCID: PMC9743240 DOI: 10.4244/eij-d-22-00372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/12/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Comparative data of durable polymer (DP) versus biodegradable polymer (BP) drug-eluting stents (DES) are limited in patients presenting with acute coronary syndrome (ACS) undergoing complex percutaneous coronary intervention (PCI). AIMS We sought to evaluate the efficacy and safety of DP-DES and BP-DES in ACS patients receiving complex PCI. METHODS This study was a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS trial. ACS patients were randomly assigned 1:1 to DP-DES or BP-DES in the HOST-REDUCE-POLYTECH-ACS trial. Complex PCI was defined as having at least 1 of the following features: ≥3 stents implanted, ≥3 lesions treated, total stent length ≥60 mm, bifurcation PCI with 2 stents, left main PCI, or heavy calcification. Patient-oriented (POCO, a composite of all-cause death, non-fatal myocardial infarction, and any repeat revascularisation) and device-oriented composite outcomes (DOCO, a composite of cardiac death, target vessel myocardial infarction, or target lesion revascularisation) were evaluated at 12 months. RESULTS Among 3,301 patients for whom full procedural data were available, 1,140 patients received complex PCI. Complex PCI was associated with higher risks of POCO and DOCO. The risks of POCO were comparable between DP-DES and BP-DES in both the complex (HR 0.87, 95% confidence interval [CI]: 0.57-1.33; p=0.522) and non-complex (HR 0.83, 95% CI: 0.56-1.24; p=0.368; p for interaction=0.884) PCI groups. DOCO was also not significantly different between DP-DES and BP-DES in both the complex (HR 0.74, 95% CI: 0.43-1.27; p=0.278) and non-complex (HR 0.67, 95% CI: 0.38-1.19; p=0.175; p for interaction=0.814) PCI groups. CONCLUSIONS In ACS patients, DP-DES and BP-DES showed similar clinical outcomes irrespective of PCI complexity.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hong-Seok Lim
- Department of Cardiology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Yong Shin
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Soon Jun Hong
- Division of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sanghyun Kim
- Division of Cardiology, Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Sang-Ho Jo
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Weon Kim
- Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Republic of Korea
| | - Sung Yun Lee
- Division of Cardiology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Seok Kyu Oh
- Department of Cardiology, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Dong-Bin Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, Bucheon, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
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Ki YJ, Lee BK, Park KW, Bae JW, Hwang D, Kang J, Han JK, Yang HM, Kang HJ, Koo BK, Kim DB, Chae IH, Moon KW, Park HW, Won KB, Jeon DW, Han KR, Choi SW, Ryu JK, Jeong MH, Cha KS, Kim HS. Prasugrel-based De-Escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With STEMI. Korean Circ J 2022; 52:304-319. [PMID: 35129316 PMCID: PMC8989793 DOI: 10.4070/kcj.2021.0293] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/01/2021] [Accepted: 12/01/2021] [Indexed: 11/24/2022] Open
Abstract
There is a fundamental trade-off that exists between ischemic and bleeding risk that must be considered in deciding the optimal strategy of dual antiplatelet therapy. Prasugrel-based de-escalation decreased the risk of net adverse clinical event (NACE) due to a reduction in bleeding in the HOST-REDUCE-POLYTECH-ACS trial. In non-ST-segment elevation acute coronary syndromes patients, prasugrel-based dose de-escalation from one-month post-percutaneous coronary intervention reduced the risk of NACE. In ST-elevation myocardial infarction (STEMI), de-escalation showed no benefit for NACE and a statistically insignificant but numerically higher rate of ischemic events. Our data raises caution about prasugrel dose reduction in higher thrombotic conditions. Background and Objectives De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events (NACEs) after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. Whether the benefits of de-escalation are sustained in highly thrombotic conditions such as ST-elevation myocardial infarction (STEMI) is unknown. We aimed to assess the efficacy and safety of de-escalation therapy in patients with STEMI or non-ST-segment elevation ACS (NSTE-ACS). Methods This is a pre-specified subgroup analysis of the HOST-REDUCE-POLYTECH-ACS trial. ACS patients were randomized to prasugrel de-escalation (5 mg daily) or conventional dose (10 mg daily) at 1-month post-percutaneous coronary intervention. The primary endpoint was a NACE, defined as a composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, clinically driven revascularization, stroke, and bleeding events of grade ≥2 Bleeding Academic Research Consortium (BARC) criteria at 1 year. Results Among 2,338 patients included in the randomization, 326 patients were diagnosed with STEMI. In patients with NSTE-ACS, the risk of the primary endpoint was significantly reduced with de-escalation (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.48–0.89; p=0.006 for de-escalation vs. conventional), mainly driven by a reduced bleeding. However, in those with STEMI, there was no difference in the occurrence of the primary outcome (HR, 1.04; 95% CI, 0.48–2.26; p=0.915; p for interaction=0.271). Conclusions Prasugrel dose de-escalation reduced the rate of NACE and bleeding, without increasing the rate of ischemic events in NSTE-ACS patients but not in STEMI patients.
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Affiliation(s)
- You-Jeong Ki
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Bong Ki Lee
- Division of Cardiology, Department of Internal Medicine, Kangwon National University, Chuncheon, Korea
| | - Kyung Woo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jang-Whan Bae
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Doyeon Hwang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung-Kyu Han
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Han-Mo Yang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun-Jae Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong-Bin Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, Bucheon, Korea
| | - In-Ho Chae
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Keon-Woong Moon
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, Suwon, Korea
| | - Hyun Woong Park
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Ki-Bum Won
- Division of Cardiology, Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Dong Woon Jeon
- Division of Cardiology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kyoo-Rok Han
- Division of Cardiology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Si Wan Choi
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Kean Ryu
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam University Hospital, Gwangju, Korea
| | - Kwang Soo Cha
- Division of Cardiology, Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Byrne RA, Hanratty CG. Durable or Biodegradable Polymer Stent Coatings: Same or Different? Circulation 2021; 143:1092-1094. [PMID: 33720774 DOI: 10.1161/circulationaha.121.052485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robert A Byrne
- Cardiovascular Research Institute Dublin, Mater Private Hospital (R.A.B., C.G.H.).,School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland (R.A.B.)
| | - Colm G Hanratty
- Cardiovascular Research Institute Dublin, Mater Private Hospital (R.A.B., C.G.H.)
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Kim HS, Kang J, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Kim SY, Park KH, Rha SW, Shin WY, Lim HS, Park K, Park KW. Durable Polymer Versus Biodegradable Polymer Drug-Eluting Stents After Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome: The HOST-REDUCE-POLYTECH-ACS Trial. Circulation 2020; 143:1081-1091. [PMID: 33205662 DOI: 10.1161/circulationaha.120.051700] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Large-scale randomized comparison of drug-eluting stents (DES) based on durable polymer versus biodegradable polymer technology is currently insufficient in patients with acute coronary syndrome (ACS). The present study aimed to prove the noninferiority of the durable polymer DES (DP-DES) compared with the biodegradable polymer DES (BP-DES) in such patients. METHODS The HOST-REDUCE-POLYTECH-ACS (Harmonizing Optimal Strategy for Treatment of Coronary Artery Diseases-Comparison of Reduction of Prasugrel Dose or Polymer Technology in ACS Patients) trial is an investigator-initiated, randomized, open-label, adjudicator-blinded, multicenter, noninferiority trial comparing the efficacy and safety of DP-DES and BP-DES in patients with ACS. The primary end point was a patient-oriented composite outcome (a composite of all-cause death, nonfatal myocardial infarction, and any repeat revascularization) at 12 months. The key secondary end point was device-oriented composite outcome (a composite of cardiac death, target-vessel myocardial infarction, or target lesion revascularization) at 12 months. RESULTS A total of 3413 patients were randomized to receive the DP-DES (1713 patients) and BP-DES (1700 patients). At 12 months, patient-oriented composite outcome occurred in 5.2% in the DP-DES group and 6.4% in the BP-DES group (absolute risk difference, -1.2%; Pnoninferiority<0.001). The key secondary end point, device-oriented composite outcome, occurred less frequently in the DP-DES group (DP-DES vs BP-DES, 2.6% vs 3.9%; hazard ratio, 0.67 [95% CI, 0.46-0.98]; P=0.038), mostly because of a reduction in target lesion revascularization. The rate of spontaneous nonfatal myocardial infarction and stent thrombosis were extremely low, with no significant difference between the 2 groups (0.6% versus 0.8%; P=0.513 and 0.1% versus 0.4%; P=0.174, respectively). CONCLUSIONS In ACS patients receiving percutaneous coronary intervention, DP-DES was noninferior to BP-DES with regard to patient-oriented composite outcomes at 12 months after index percutaneous coronary intervention. Registration: URL: https://wwwclinicaltrials.gov; Unique identifier: NCT02193971.
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Affiliation(s)
- Hyo-Soo Kim
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | - Jeehoon Kang
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | - Doyeon Hwang
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | - Jung-Kyu Han
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | - Han-Mo Yang
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | - Hyun-Jae Kang
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | - Bon-Kwon Koo
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
| | | | - Keun-Ho Park
- Chosun University Hospital, Gwangju, Korea (K-H.P.)
| | | | - Won-Yong Shin
- Soon Chun Hyang University Cheonan Hospital, Cheonan, Korea (W-Y.S.)
| | - Hong-Seok Lim
- Ajou University School of Medicine, Suwon, Korea (H-S.L.)
| | | | - Kyung Woo Park
- Seoul National University Hospital, Korea (H-S.K., J.K., D.H., J-K.H., H-M.Y., H-J.K., B-K.K., K.W.P.)
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Kim HS, Kang J, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Rhew JY, Chun KJ, Lim YH, Bong JM, Bae JW, Lee BK, Park KW. Prasugrel-based de-escalation of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (HOST-REDUCE-POLYTECH-ACS): an open-label, multicentre, non-inferiority randomised trial. Lancet 2020; 396:1079-1089. [PMID: 32882163 DOI: 10.1016/s0140-6736(20)31791-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND A potent P2Y12 inhibitor-based dual antiplatelet therapy is recommended for up to 1 year in patients with acute coronary syndrome receiving percutaneous coronary intervention (PCI). The greatest benefit of the potent agent is during the early phase, whereas the risk of excess bleeding continues in the chronic maintenance phase. Therefore, de-escalation of antiplatelet therapy might achieve an optimal balance between ischaemia and bleeding. We aimed to investigate the safety and efficacy of a prasugrel-based dose de-escalation therapy. METHODS HOST-REDUCE-POLYTECH-ACS is a randomised, open-label, multicentre, non-inferiority trial done at 35 hospitals in South Korea. We enrolled patients with acute coronary syndrome receiving PCI. Patients meeting the core indication for prasugrel were randomly assigned (1:1) to the de-escalation group or conventional group using a web-based randomisation system. The assessors were masked to the treatment allocation. After 1 month of treatment with 10 mg prasugrel plus 100 mg aspirin daily, the de-escalation group received 5 mg prasugrel, while the conventional group continued to receive 10 mg. The primary endpoint was net adverse clinical events (all-cause death, non-fatal myocardial infarction, stent thrombosis, repeat revascularisation, stroke, and bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria) at 1 year. The absolute non-inferiority margin for the primary endpoint was 2·5%. The key secondary endpoints were efficacy outcomes (cardiovascular death, myocardial infarction, stent thrombosis, and ischaemic stroke) and safety outcomes (bleeding events of BARC grade ≥2). The primary analysis was in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02193971. RESULTS From Sept 30, 2014, to Dec 18, 2018, 3429 patients were screened, of whom 1075 patients did not meet the core indication for prasugrel and 16 were excluded due to randomisation error. 2338 patients were randomly assigned to the de-escalation group (n=1170) or the conventional group (n=1168). The primary endpoint occurred in 82 patients (Kaplan-Meier estimate 7·2%) in the de-escalation group and 116 patients (10·1%) in the conventional group (absolute risk difference -2·9%, pnon-inferiority<0·0001; hazard ratio 0·70 [95% CI 0·52-0·92], pequivalence=0·012). There was no increase in ischaemic risk in the de-escalation group compared with the conventional group (0·76 [0·40-1·45]; p=0·40), and the risk of bleeding events was significantly decreased (0·48 [0·32-0·73]; p=0·0007). INTERPRETATION In east Asian patients with acute coronary syndrome patients receiving PCI, a prasugrel-based dose de-escalation strategy from 1 month after PCI reduced the risk of net clinical outcomes up to 1 year, mainly driven by a reduction in bleeding without an increase in ischaemia. FUNDING Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio.
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Affiliation(s)
- Hyo-Soo Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul, South Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul, South Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul, South Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul, South Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, South Korea
| | | | - Kook-Jin Chun
- Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Young-Hyo Lim
- Hanyang University Seoul Hospital, Seoul, South Korea
| | | | | | - Bong Ki Lee
- Kangwon National University, Chuncheon, South Korea
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Kim HK, Ahn Y, Chang K, Jeong YH, Hahn JY, Choo EH, Kim MC, Kim HS, Kim W, Cho MC, Jang Y, Kim CJ, Jeong MH, Chae SC. 2020 Korean Society of Myocardial Infarction Expert Consensus Document on Pharmacotherapy for Acute Myocardial Infarction. Korean Circ J 2020; 50:845-866. [PMID: 32969206 PMCID: PMC7515755 DOI: 10.4070/kcj.2020.0196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/01/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023] Open
Abstract
Clinical practice guidelines published by the European Society of Cardiology and the American College of Cardiology/American Heart Association summarize the available evidence and provide recommendations for health professionals to enable appropriate clinical decisions and improve clinical outcomes for patients with acute myocardial infarction (AMI). However, most current guidelines are based on studies in non-Asian populations in the pre-percutaneous coronary intervention (PCI) era. The Korea Acute Myocardial Infarction Registry is the first nationwide registry to document many aspects of AMI from baseline characteristics to treatment strategies. There are well-organized ongoing and published randomized control trials especially for antiplatelet therapy among Korean patients with AMI. Here, members of the Task Force of the Korean Society of Myocardial Infarction review recent published studies during the current PCI era, and have summarized the expert consensus for the pharmacotherapy of AMI.
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Affiliation(s)
- Hyun Kuk Kim
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Joo Yong Hahn
- Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyo Soo Kim
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul, Korea
| | - Weon Kim
- Division of Cardiovascular, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Yangsoo Jang
- Cardiology Division, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chong Jin Kim
- Cardiovascular Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea.
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
- School of Medicine, Kyungpook National University, Daegu, Korea.
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Jin CD, Kim MH, Guo LZ, Jin E, Shin ES, Ann SH, Cho YR, Park JS, Kim SJ, Lee MS. Pharmacodynamic study of prasugrel or clopidogrel in non-ST-elevation acute coronary syndrome with CYP2C19 genetic variants undergoing percutaneous coronary intervention (PRAISE-GENE trial). Int J Cardiol 2020; 305:11-17. [DOI: 10.1016/j.ijcard.2020.01.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/12/2020] [Accepted: 01/24/2020] [Indexed: 11/26/2022]
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Parker J, Powell L, Mawson S. Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review. J Med Internet Res 2020; 22:e15981. [PMID: 31913131 PMCID: PMC6996755 DOI: 10.2196/15981] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness. OBJECTIVE This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors. METHODS Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs. RESULTS In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants' stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P≤.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years. CONCLUSIONS This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery. TRIAL REGISTRATION PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=57715.
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Huo Y, Jeong YH, Gong Y, Wang D, He B, Chen J, Fu G, Chen Y, Li J, Li Y, Goto S, Tantry US, Gurbel PA, Ahn JH, Kim HS, Ho Jeong M, Han Y, Smith SC, Ge J. 2018 update of expert consensus statement on antiplatelet therapy in East Asian patients with ACS or undergoing PCI. Sci Bull (Beijing) 2019; 64:166-179. [PMID: 36659616 DOI: 10.1016/j.scib.2018.12.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/17/2018] [Accepted: 12/07/2018] [Indexed: 01/21/2023]
Abstract
East Asians are the most populous race in the world and their health status is an important global issue. Compared with Caucasian populations, East Asian patients have a different benefit/risk ratio when using antithrombotic treatment. Despite this observation, treatment strategies in East Asian patients are mostly based on the American and European guidelines. Despite a lower platelet inhibitory response to clopidogrel, East Asian patients show a similar or even a lower rate of ischemic event occurrence and higher bleeding risk compared with Caucasian patients. For potent P2Y12 inhibitors (ticagrelor and prasugrel), East Asian patients have shown less favorable net clinical benefits compared with Caucasian patients, which may be related to differences in pharmacokinetic/pharmacodynamic profiles and therapeutic zone of antiplatelet effect. This updated consensus mainly focuses on state-of-the-art and current controversies in the East Asian population. In addition, when East Asian patients are administered potent P2Y12 receptor inhibitors, the strategies and ongoing trials to overcome the related hurdles are discussed.
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Affiliation(s)
- Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China.
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University, Changwon Hospital, Changwon 51472, Republic of Korea
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Daowen Wang
- Division of Cardiology, Internal Medicine Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital affiliated to Shanghai Jiaotong University, Shanghai 200030, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong General Hospital, Guangzhou 510080, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLAG General Hospital, Beijing 100853, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa 2591193, Japan
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA 22042, USA
| | - Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA 22042, USA
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University, Changwon Hospital, Changwon 51472, Republic of Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Myung Ho Jeong
- The Heart Research Center Nominated by Korea Ministry of Health and Welfare, Chonnam National University Hospital, Gwangju 61469, Republic of Korea
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Junbo Ge
- Department of Cardiology, Fudan University Zhongshan Hospital, Shanghai 200032, China.
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