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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [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] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Tan CK, Wu DBC, Joseph Tan SY, Imran SS, Wee XT, Tan SYD. Validating the Prognostic Utility of the ABCD-GENE Score in Asian Patients with Acute Coronary Syndrome Patients on Clopidogrel. Eur Cardiol 2023; 18:e60. [PMID: 38023338 PMCID: PMC10658354 DOI: 10.15420/ecr.2023.27] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background The ABCD-GENE score, which links cytochrome P450 2C19 (CYP2C19) phenotype and high platelet reactivity (HPR) to the risk of major adverse cardiovascular events (MACE) in clopidogrel users, has been validated in white and Japanese populations. The prognostic implications of the score in other Asian cohorts, however, have been largely unchartered. The aim of this study was to validate the prognostic utility of the ABCD-GENE score in a heterogeneous Asian acute coronary syndrome (ACS) cohort. Methods and Results In this single-centre, retrospective cohort evaluation of 423 ACS patients, the objectives were to characterise the best cut-off score for MACE prognostication by comparing the adjusted 1-year risk of MACE between groups above and below the candidate cut-off scores using Cox regression; and for on-clopidogrel HPR prediction using receiver operating characteristic (ROC) analysis and Youden's index. In the adjusted Cox model, an ABCD-GENE score cut-off at 10 points significantly predicts the 1-year risk of MACE (adjusted HR 3.771; 95% CI [1.041-13.661]). Female sex, baseline LDL, history of ACS and angiotensin receptor blocker use were additional independent predictors of MACE. On ROC analysis the ideal cut-off for HPR prediction was 7 points. However, that did not independently predict the 1-year risk of MACE (adjusted HR 1.595; 95% CI [0.425-5.989]). Conclusion The original ABCD-GENE score 10-point cut-off moderately predicts MACE in a heterogeneous, Asian ACS population at 1 year. Additional predictors of MACE were also identified in the present cohort, and these findings should be prospectively validated in larger ACS cohorts.
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Affiliation(s)
| | - David Bin-Chia Wu
- Saw Swee Hock School of Public Health, National University of SingaporeSingapore
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Hsin CH, Dingemanse J, Henrich A, Bernaud C, Gehin M, Krause A. Mind the Gap: Model-Based Switching from Selatogrel to Maintenance Therapy with Oral P2Y12 Receptor Antagonists. Biomolecules 2023; 13:1365. [PMID: 37759765 PMCID: PMC10527299 DOI: 10.3390/biom13091365] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Background: The P2Y12 receptor antagonist selatogrel is being developed for subcutaneous self-administration with a ready-to-use autoinjector at the onset of acute myocardial infarction (AMI) symptoms. The unique pharmacological profile of selatogrel (fast, potent, and short-acting) can bridge the time gap between the onset of AMI and first medical care. A clinical Phase 1 study showed a time-dependent pharmacodynamic interaction between selatogrel and loading doses of clopidogrel and prasugrel. As treatment switching is a common clinical practice, the assessment of subsequent switching from a clopidogrel loading dose to the first maintenance dose of oral P2Y12 receptor antagonists is highly relevant. Objectives: Model-based predictions of inhibition of platelet aggregation (IPA) for the drugs triggering pharmacodynamic interactions were to be derived to support clinical guidance on the transition from selatogrel to oral P2Y12 receptor antagonists. Methods: Scenarios with selatogrel 16 mg administration or placebo followed by a clopidogrel loading dose and, in turn, prasugrel or ticagrelor maintenance doses at different times of administration were studied. Population pharmacokinetic/pharmacodynamic modeling and simulations of different treatment scenarios were used to derive quantitative estimates for IPA over time. Results: Following selatogrel/placebo and a clopidogrel loading dose, maintenance treatment with ticagrelor or a prasugrel loading dose followed by maintenance treatment quickly achieved sustained IPA levels above 80%. Prior to maintenance treatment, a short time span from 18 to 24 h was identified where IPA levels were predicted to be lower with selatogrel than with placebo if clopidogrel was administered 12 h after selatogrel or placebo. Predicted IPA levels reached with placebo alone and a clopidogrel loading dose at 4 h were consistently lower than with selatogrel administration, followed by a clopidogrel loading dose at 12 h. If a clopidogrel loading dose is administered at 12 h, selatogrel maintains higher IPA levels up to 16 h. IPA levels are subsequently lower than on the placebo until the administration of the first maintenance dose. Conclusions: Model-based predictions informed the transition from selatogrel subcutaneous administration to oral P2Y12 therapy. The application of modeling techniques illustrates the value of employing pharmacokinetic and pharmacodynamic modeling for the simulation of various clinical scenarios of switching therapies.
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Affiliation(s)
| | | | | | | | | | - Andreas Krause
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd., 4123 Allschwil, Switzerland
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Lee WC, Fang CY, Tsai YH, Hsieh YY, Chen TY, Fang YN, Chen HC, Wu PJ, Fang HY. Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in East-Asian Patients with Acute Coronary Syndrome: Large Cohort Study. Am J Cardiovasc Drugs 2023; 23:573-581. [PMID: 37610643 DOI: 10.1007/s40256-023-00603-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
AIM A high risk of bleeding is observed in East Asian patients with acute coronary syndrome (ACS). Therefore, the choice between two antiplatelet therapy drugs, ticagrelor and clopidogrel, remains controversial in this population with ACS. This study aimed to use a large cohort database to assess the clinical outcomes of ticagrelor and clopidogrel therapy, including major bleeding, recurrent ACS, and mortality, in this population. METHODS Between January 2009 and December 2019, 43,696 patients were diagnosed with ACS based on the medical history (International Classification of Diseases [ICD] code) of the Chang Gung Research Database. After excluding patients without percutaneous coronary intervention, with concurrent medical problems, and on non-standard dual antiplatelet therapy (DAPT) or a single antiplatelet agent, 18,046 patients were recruited for analysis. Ticagrelor- and clopidogrel-based DAPT were administered to 3666 patients and 14,380 patients, respectively. Baseline characteristics and clinical outcomes were compared between the two groups. A total of 4225 patients were defined as a high-bleeding-risk subgroup according to Academic Research Consortium for High Bleeding Risk (ARC-HBR) score (met one major or two minor criteria), of which 466 and 3759 patients received ticagrelor- and clopidogrel-based DAPT, respectively. RESULTS Before propensity score matching (PSM), younger age, higher prevalence of male sex, and higher body mass index were noted in the ticagrelor-based DAPT group in the whole cohort and high-bleeding-risk subgroup. After PSM, no difference in baseline characteristics and comorbidities between ticagrelor-based and clopidogrel-based DAPT groups in the whole cohort and high-bleeding-risk subgroup was noted. The Kaplan-Meier curves of recurrent ACS and major bleeding were significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of cardiovascular (CV) and all-cause mortality showed no significant differences. After PSM, in the high-bleeding-risk subgroup, the Kaplan-Meier curve of recurrent ACS was significantly lower in the ticagrelor-based DAPT group than in the clopidogrel-based DAPT group, and that of major bleeding, CV, and all-cause mortality showed no significant differences. CONCLUSION In this large cohort study, patients receiving ticagrelor-based DAPT were at lower risk of recurrent ACS compared to those receiving clopidogrel-based DAPT, especially in the patients with myocardial infarction. Ticagrelor-based DAPT did not result in a higher risk of major bleeding in the whole ACS population and high-bleeding-risk subgroup. The rate of CV and all-cause mortality were similar between both the groups.
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Affiliation(s)
- Wei-Chieh Lee
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan.
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Hsuan Tsai
- Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yun-Yu Hsieh
- Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tien-Yu Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Jen-Ai Hospital, Taichung, Taiwan
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Li J, Wang Q, Wu C, Qu X, Zhang L, He X, Ma S, Qiu M, Wang X. Safety and Efficacy of Ticagrelor versus Clopidogrel in East Asian Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention Treated with Dual Antiplatelet Therapy: A Meta-Analysis of Randomized Controlled Trials. Cardiology 2023; 148:363-373. [PMID: 37094558 PMCID: PMC10614237 DOI: 10.1159/000530602] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023]
Abstract
INTRODUCTION The treatment strategy for dual antiplatelet therapy (DAPT) with ticagrelor has been controversial in East Asian patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Our meta-analysis aimed to demonstrate whether intensified antithrombotic regimens with ticagrelor plus aspirin have more beneficial effects and fewer adverse events compared to those of clopidogrel plus aspirin in East Asian patients with ACS undergoing PCI. METHODS We searched PubMed, Embase, Web of Science, ScienceDirect, Clinical Trials, Cochrane Library, and Chinese Clinical Trial Registry for randomized controlled trials (RCTs) comparing the efficacy of DAPT with ticagrelor or clopidogrel plus aspirin for secondary prevention of ACS in East Asian patients undergoing PCI. Risk ratios (RRs) and 95% confidence intervals (CIs) were used as the metrics of choice for assessing treatment effects. The primary endpoint was bleeding events, and the secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs, including cardiovascular death, nonfatal myocardial infarction [MI], and stroke), all-cause death, and definite/probable/possible stent thrombosis. The I2 index was used to assess heterogeneity. RESULTS Six RCTs involving a total of 2,725 patients met the inclusion criteria. The incidence of all bleeding events with ticagrelor was higher than that with clopidogrel (RR, 1.65; 95% CI, 1.31-2.07), but the incidence of MACCE was not significantly different between the two groups (RR, 1.08; 95% CI, 0.54-2.16). All-cause death (RR, 1.10; 95% CI, 0.67-1.79), cardiovascular death (RR, 1.42; 95% CI, 0.68-2.98), nonfatal MI (RR, 0.92; 95% CI, 0.48-1.78), stroke (RR, 1.00; 95% CI, 0.40-2.50), and stent thrombosis (RR, 0.76; 95% CI, 0.19-2.98) were not statistically different between the two groups. CONCLUSION Ticagrelor increased the risk of bleeding and did not increase treatment efficacy compared to that of clopidogrel in the East Asian population who have ACS treated with PCI.
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Affiliation(s)
- Jingyuan Li
- College of Life Science and Biopharmaceutical, Shenyang Pharmaceutical University, Shenyang, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Qian Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Chunliu Wu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaoyu Qu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Lei Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaofeng He
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozeng Wang
- College of Life Science and Biopharmaceutical, Shenyang Pharmaceutical University, Shenyang, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Kim Y, Jeong MH, An M, Cho K, Hong Y, Kim J, Ahn Y. Long-term use of clopidogrel versus ticagrelor or prasugrel in patients with acute myocardial infarction after percutaneous coronary intervention. PLoS One 2023; 18:e0278993. [PMID: 36821598 PMCID: PMC9949675 DOI: 10.1371/journal.pone.0278993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 10/27/2022] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the long-term clinical outcomes of dual antiplatelet therapy (DAPT) with clopidogrel and DAPT with ticagrelor or prasugrel in patients with acute myocardial infarction (AMI) who underwent coronary intervention. METHODS Between November 2011 and December 2015, a total of 13,104 patients with AMI were enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry. Among them, 4,696 patients who received DAPT for more than 24 months were categorized into two groups: the clopidogrel group (n = 4,053) and ticagrelor or prasugrel group (n = 643). Propensity score matching (PSM) was used to reduce the bias due to confounding variables. Following PSM, the impacts of P2Y12 inhibitors on the clinical outcomes in both groups were compared during a 36-month clinical follow-up period. RESULTS There were no significant differences in clinical outcomes in terms of cardiac death (7.1% vs. 9.7%, p = 0.101), stroke (1.4% vs. 1.0%, p = 0.436), major bleeding (0.5% vs. 0.8%, p = 0.478), major adverse cardiac events (MACE) (21.6% vs. 20.5%, p = 0.626), and net adverse cardiac event (NACE) (22.1% vs. 21.3%, p = 0.731) between the groups. The ticagrelor or prasugrel group had a lower incidence of recurrent percutaneous coronary intervention (PCI) (12.2% vs. 7.6%, p = 0.006) than the clopidogrel group. However, no differences were observed in the cumulative incidences of 3-year NACE between the ticagrelor or prasugrel and clopidogrel groups. CONCLUSIONS Cumulative incidences of long-term NACE did not differ between the two groups. Therefore, the type and duration of DAPT should be customized for each patient with AMI.
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Affiliation(s)
- Yuri Kim
- College of Nursing, Chonnam National University, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital and Medical School, Gwangju, Korea,* E-mail:
| | - Minjeong An
- College of Nursing, Chonnam National University, Gwangju, Korea
| | - Kyunghoon Cho
- Department of Cardiology, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Youngjoon Hong
- Department of Cardiology, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Juhan Kim
- Department of Cardiology, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital and Medical School, Gwangju, Korea
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Lee WL, Wang YC, Su CS, Lee HF, Tung YC, Liu PY, Su CH, Kuo FY, Lin WS, Chu PH, Lu TM, Lo PH, Tsukiyama S, Yang WC, Cheng LC, Yin WH, Lin YH. A HANC Risk Stratification Score for Antiplatelet Therapy Optimization with Low-Dose Prasugrel in Taiwanese Acute Coronary Syndrome Patients from the Switch Study. Acta Cardiol Sin 2022; 38:751-764. [PMID: 36440250 PMCID: PMC9692225 DOI: 10.6515/acs.202211_38(6).20220702a] [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] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND A significant proportion of acute coronary syndrome (ACS) patients experience high on-treatment platelet reactivity (HPR) on clopidogrel-based dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). OBJECTIVES This study assessed key independent risk factors associated with significant HPR risk on clopidogrel, but not prasugrel, in the Switch Study cohort of 200 Taiwanese ACS patients who switched from clopidogrel to low-dose prasugrel for maintenance DAPT after PCI. METHODS Univariate analysis and stepwise multivariate logistic regression analysis were conducted to identify key independent risk factors for HPR on clopidogrel, but not prasugrel. RESULTS A HANC [H: low hemoglobin (< 13 g/dL for men and < 12 g/dL for women); A: age ≥ 65 years; N: non-ST elevation myocardial infarction; C: chronic kidney disease as defined by estimated glomerular filtration rate < 60 mL/min] risk stratification score was developed, and demonstrated optimal sensitivity and specificity at a cutoff score of ≥ 2. The HANC score compared favorably against the recently validated ABCD score in the full Switch Study cohort (n = 200), and the ABCD-GENE score in a genotyped cohort (n = 102). CONCLUSIONS The HANC score may serve to alert clinicians to patients at potentially higher HPR risk on clopidogrel, but not prasugrel. Further research to validate this score and assess its correlation with clinical outcomes is warranted.
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Affiliation(s)
- Wen-Lieng Lee
- Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei
| | - Chieh-Shou Su
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung;
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School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Hsin-Fu Lee
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan;
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Division of Cardiology, Department of Internal Medicine, New Taipei City Municipal Tucheng Hospital, New Taipei City
| | - Ying-Chang Tung
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou, Taoyuan
| | - Ping-Yen Liu
- Division of Cardiology, Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University;
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Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan
| | - Cheng-Huang Su
- Cardiovascular Center, MacKay Memorial Hospital, Taipei;
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MacKay Medical College, New Taipei City
| | - Feng-Yu Kuo
- Division of Cardiology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital and National Defense Medical Center, Taipei
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan
| | - Tse-Min Lu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei;
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Division of Cardiology, Department of Medicine;
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Healthcare & Service Center, Taipei Veterans General Hospital, Taipei
| | - Ping-Han Lo
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | | | | | | | - Wei-Hsian Yin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei;
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Division of Cardiology, Heart Center, Cheng Hsin General Hospital
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei;
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Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
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Pradhan A, Tiwari A, Caminiti G, Salimei C, Muscoli S, Sethi R, Perrone MA. Ideal P2Y12 Inhibitor in Acute Coronary Syndrome: A Review and Current Status. IJERPH 2022; 19:8977. [PMID: 35897347 PMCID: PMC9331944 DOI: 10.3390/ijerph19158977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
Dual antiplatelet therapy (DAPT) has remained the cornerstone for management of acute coronary syndrome (ACS) over the years. Clopidogrel has been the quintessential P2Y12 receptor (platelet receptor for Adenosine 5′ diphosphate) inhibitor for the past two decades. With the demonstration of unequivocal superior efficacy of prasugrel/ticagrelor over clopidogrel, guidelines now recommend these agents in priority over clopidogrel in current management of ACS. Cangrelor has revived the interest in injectable antiplatelet therapy too. Albeit the increased efficacy of these newer agents comes at the cost of increased bleeding and this becomes more of a concern when combined with aspirin. Which P2Y12i is superior over another has been intensely debated over last few years after the ISAR-REACT 5 study with inconclusive data. Three novel antiplatelet agents are already in the pipeline for ACS with all of them succeeding in phase II studies. The search for an ideal antiplatelet remains a need of the hour for optimal reduction of ischemic events in ACS.
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Xu O, Hartmann J, Tang YD, Dias J. The Use of Thromboelastography in Percutaneous Coronary Intervention and Acute Coronary Syndrome in East Asia: A Systematic Literature Review. J Clin Med 2022; 11:jcm11133652. [PMID: 35806936 PMCID: PMC9267871 DOI: 10.3390/jcm11133652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/07/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 12/04/2022] Open
Abstract
Dual antiplatelet therapy (DAPT), alongside percutaneous coronary intervention (PCI), is central to the prevention of ischemic events following acute coronary syndrome (ACS). However, response to therapy can vary due to several factors including CYP2C19 gene variation, which shows increased prevalence in East Asian populations. DAPT responsiveness can be assessed using techniques such as light transmission aggregometry (LTA), VerifyNow® and thromboelastography with the PlateletMapping® assay, and there is increasing focus on the utility of platelet function testing to guide individualized treatment. This systematic literature review of one English and three Chinese language databases was conducted to evaluate the evidence for the utility of thromboelastography in ACS/PCI in East Asia. The search identified 42 articles from the English language and 71 articles from the Chinese language databases which fulfilled the pre-determined inclusion criteria, including 38 randomized controlled trials (RCTs). The identified studies explored the use of thromboelastography compared to LTA and VerifyNow in monitoring patient responsiveness to DAPT, as well as predicting ischemic risk, with some studies suggesting that thromboelastography is better able to detect low DAPT response than LTA. Other studies, including one large RCT, described the use of thromboelastography in guiding the escalation of DAPT, with some evidence suggesting that such protocols reduce ischemic events without increasing the risk of bleeding. There was also evidence suggesting that thromboelastography can be used to identify individuals with DAPT hyporesponsiveness genotypes and could potentially guide treatment by adjusting therapy in patients depending on responsiveness.
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Affiliation(s)
- Ou Xu
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, MA 02110, USA; (O.X.); (J.H.)
| | - Jan Hartmann
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, MA 02110, USA; (O.X.); (J.H.)
| | - Yi-Da Tang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing 100083, China;
| | - Joao Dias
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, MA 02110, USA; (O.X.); (J.H.)
- Correspondence:
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10
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Ng AKY, Ng PY, Ip A, Ling IWH, Lam LT, Siu CW. Incidence, Prediction, and Outcomes of Major Bleeding After Percutaneous Coronary Intervention in Chinese Patients. JACC Asia 2022; 2:341-350. [PMID: 36338416 PMCID: PMC9627816 DOI: 10.1016/j.jacasi.2021.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/06/2021] [Accepted: 12/20/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND The patterns of late major bleeding (MB) after percutaneous coronary intervention (PCI) remain unknown in Chinese patients. OBJECTIVES This study sought to determine the incidence, prediction, and long-term outcomes of late MB in Chinese patients. METHODS This was a retrospective cohort study from 14 hospitals in Hong Kong. Participants were patients undergoing first-time PCI without MB within 30 days or death within 1 year. Patients were stratified by the presence of late MB, defined as MB between 30 and 365 days. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiac events (MACE). RESULTS A total of 32,057 patients were analyzed. After adjustment for baseline characteristics, periprocedural characteristics, and medications on discharge, the risks of all-cause mortality at 5 years were significantly higher with late MB (HR: 2.15; 95% CI: 1.92-2.41; P < 0.001). Late MB was also associated with a higher risk of MACE (HR: 1.57; 95% CI: 1.03-1.50; P < 0.001), myocardial infarction (HR: 1.25; 95% CI: 1.04-1.52; P = 0.02), and stroke (HR: 1.38; 95% CI: 1.09-1.73; P = 0.006). The CARDIAC (anti-Coagulation therapy, Age, Renal insufficiency, Drop In hemoglobin, baseline Anemia in Chinese patients) score had a good discriminating power for prediction of MB within 365 days (area under the receiver-operating characteristic curve: 0.76). CONCLUSIONS Late MB was independently associated with a higher risk of mortality, MACE, myocardial infarction, and stroke in patients undergoing PCI. The CARDIAC score is a simple model that can predict MB after PCI. Prevention of MB represents an important strategy to optimize cardiovascular outcomes for patients undergoing PCI.
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Affiliation(s)
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong SAR, China
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - April Ip
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | | | - Lap-Tin Lam
- Cardiac Medical Unit, Grantham Hospital, Hong Kong SAR, China
| | - Chung-Wah Siu
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong SAR, China
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11
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Her AY, Jeong YH, Kim BK, Joo HJ, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Kim HS, Kim MH, Lim DS, Shin ES. Platelet Function and Genotype after DES Implantation in East Asian Patients: Rationale and Characteristics of the PTRG-DES Consortium. Yonsei Med J 2022; 63:413-421. [PMID: 35512743 PMCID: PMC9086699 DOI: 10.3349/ymj.2022.63.5.413] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/31/2021] [Accepted: 01/18/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Platelet function test (PFT) results and genotype hold unique prognostic implications in East Asian patients. The aim of the PTRG-DES (Platelet function and genoType-Related long-term proGnosis in Drug-Eluting Stent-treated Patients with coronary artery disease) consortium is to assess the clinical impact thereof on long-term clinical outcomes in Korean patients with coronary artery disease during dual antiplatelet therapy (DAPT) including clopidogrel. MATERIALS AND METHODS Searching publications on the PubMed, we reviewed clopidogrel treatment studies with PFT and/or genotype data for potential inclusion in this study. Lead investigators were invited to share PFT/genotype results, patient characteristics, and clinical outcomes to evaluate relationships among them. RESULTS Nine registries from 32 academic centers participated in the PTRG-DES consortium, contributing individual patient data from 13160 patients who underwent DES implantation between July 2003 and August 2018. The PTRG-PFT cohort was composed of 11714 patients with available VerifyNow assay results. Platelet reactivity levels reached 218±79 P2Y12 reaction units (PRU), and high on-clopidogrel platelet reactivity based on a consensus-recommended cutoff (PRU >208) was observed in 55.9%. The PTRG-Genotype cohort consisted of 8163 patients with candidate genotypes related with clopidogrel responsiveness. Of those with cytochrome P450 (CYP) 2C19 genotype, frequencies of carrying one and two loss-of-function allele (s) (*2 or *3) were 47.9% (intermediate metabolizers) and 14.2% (poor metabolizers), respectively. CONCLUSION The PTRG-DES consortium highlights unique values for on-clopidogrel platelet reactivity and CYP2C19 phenotype that may be important to developing optimal antiplatelet regimens in East Asian patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04734028.
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Affiliation(s)
- Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Joon Joo
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Gyun Ahn
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Yeup Lee
- Division of Cardiology, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Moo Hyun Kim
- Department of Cardiology, Dong-A University Hospital, Busan, Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eun-Seok Shin
- Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
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12
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Tan JW, Lo ST, Chew DP. New balance to an old complex problem. Catheter Cardiovasc Interv 2022; 99 Suppl 1:1376-1377. [PMID: 35475544 DOI: 10.1002/ccd.30192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jack Wc Tan
- National Heart Centre, Singapore, Singapore.,Sengkang General Hospital, Singapore, Singapore
| | - Sidney Th Lo
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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13
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Kuo FY, Lee CH, Lan WR, Su CH, Lee WL, Wang YC, Lin WS, Chu PH, Lu TM, Lo PH, Tsukiyama S, Yang WC, Cheng LC, Huang CL, Yin WH, Liu PY. Effect of CYP2C19 status on platelet reactivity in Taiwanese acute coronary syndrome patients switching to prasugrel from clopidogrel: Switch Study. J Formos Med Assoc 2022; 121:1786-1797. [DOI: 10.1016/j.jfma.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/13/2021] [Accepted: 01/12/2022] [Indexed: 10/19/2022] Open
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Ng AKY, Ng PY, Ip A, Lam LT, Siu CW. Trade-off of major bleeding versus myocardial infarction on mortality after percutaneous coronary intervention. Open Heart 2022; 9:openhrt-2021-001861. [PMID: 35017315 PMCID: PMC8753444 DOI: 10.1136/openhrt-2021-001861] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/21/2021] [Indexed: 11/03/2022] Open
Abstract
Background The choice of antithrombotic therapy after percutaneous coronary intervention (PCI) is heavily dependent on the relative trade-off between major bleeding (MB) and myocardial infarction (MI). However, the mortality trade-off was mostly described in Western populations and remained unknown in East Asians. Method This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Participants were patients undergoing first-time PCI and survived for the first year. Patients were stratified by the presence of MB and MI during the first year. The primary endpoint was all-cause mortality between 1 and 5 years after PCI. The secondary endpoint was cardiovascular mortality. Results A total of 32 180 patients were analysed. After adjustment for baseline characteristics and using patients with neither events as reference, the risks of all-cause mortality were increased in patients with MI only (HR, 1.63; 95% CI 1.45 to 1.84; p<0.001), further increased in those with MB only (HR, 2.11, 95% CI 1.86 to 2.39; p<0.001) and highest in those with both (HR, 2.92; 95% CI 2.39 to 3.56; p<0.001). In both Cox regression and propensity score analyses, MB had a stronger impact on all-cause mortality than MI, but similar impact on cardiovascular mortality. Conclusions Both MB and MI within the first year after PCI were associated with increase in all-cause and cardiovascular mortality in Chinese patients, but the impact was stronger with MB.
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Affiliation(s)
| | - Pauline Yeung Ng
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong, Hong Kong.,Department of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
| | - April Ip
- Department of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
| | - Lap Tin Lam
- Cardiac Medical Unit, Grantham Hospital, Hong Kong, Hong Kong
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, University of Hong Kong Faculty of Medicine, Hong Kong, Hong Kong
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15
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Yeh CH, Chou YJ, Tsai TH, Hsu PWC, Li CH, Chan YH, Tsai SF, Ng SC, Chou KM, Lin YC, Juan YH, Fu TC, Lai CC, Sytwu HK, Tsai TF. Artificial-Intelligence-Assisted Discovery of Genetic Factors for Precision Medicine of Antiplatelet Therapy in Diabetic Peripheral Artery Disease. Biomedicines 2022; 10:biomedicines10010116. [PMID: 35052795 PMCID: PMC8773099 DOI: 10.3390/biomedicines10010116] [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: 12/05/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022] Open
Abstract
An increased risk of cardiovascular events was identified in patients with peripheral artery disease (PAD). Clopidogrel is one of the most widely used antiplatelet medications. However, there are heterogeneous outcomes when clopidogrel is used to prevent cardiovascular events in PAD patients. Here, we use an artificial intelligence (AI)-assisted methodology to identify genetic factors potentially involved in the clopidogrel-resistant mechanism, which is currently unclear. Several discoveries can be pinpointed. Firstly, a high proportion (>50%) of clopidogrel resistance was found among diabetic PAD patients in Taiwan. Interestingly, our result suggests that platelet function test-guided antiplatelet therapy appears to reduce the post-interventional occurrence of major adverse cerebrovascular and cardiac events in diabetic PAD patients. Secondly, AI-assisted genome-wide association study of a single-nucleotide polymorphism (SNP) database identified a SNP signature composed of 20 SNPs, which are mapped into 9 protein-coding genes (SLC37A2, IQSEC1, WASHC3, PSD3, BTBD7, GLIS3, PRDM11, LRBA1, and CNR1). Finally, analysis of the protein connectivity map revealed that LRBA, GLIS3, BTBD7, IQSEC1, and PSD3 appear to form a protein interaction network. Intriguingly, the genetic factors seem to pinpoint a pathway related to endocytosis and recycling of P2Y12 receptor, which is the drug target of clopidogrel. Our findings reveal that a combination of AI-assisted discovery of SNP signatures and clinical parameters has the potential to develop an ethnic-specific precision medicine for antiplatelet therapy in diabetic PAD patients.
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Affiliation(s)
- Chi-Hsiao Yeh
- Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.L.); (Y.-H.J.); (T.-C.F.)
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Yi-Ju Chou
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli 350, Taiwan; (Y.-J.C.); (P.W.-C.H.); (S.-F.T.)
| | - Tsung-Hsien Tsai
- Advanced Tech BU, Acer Inc., New Taipei City 221, Taiwan; (T.-H.T.); (C.-H.L.); (Y.-H.C.)
| | - Paul Wei-Che Hsu
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli 350, Taiwan; (Y.-J.C.); (P.W.-C.H.); (S.-F.T.)
| | - Chun-Hsien Li
- Advanced Tech BU, Acer Inc., New Taipei City 221, Taiwan; (T.-H.T.); (C.-H.L.); (Y.-H.C.)
| | - Yun-Hsuan Chan
- Advanced Tech BU, Acer Inc., New Taipei City 221, Taiwan; (T.-H.T.); (C.-H.L.); (Y.-H.C.)
| | - Shih-Feng Tsai
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli 350, Taiwan; (Y.-J.C.); (P.W.-C.H.); (S.-F.T.)
| | - Soh-Ching Ng
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Keelung 204, Taiwan; (S.-C.N.); (K.-M.C.)
| | - Kuei-Mei Chou
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Keelung 204, Taiwan; (S.-C.N.); (K.-M.C.)
| | - Yu-Ching Lin
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.L.); (Y.-H.J.); (T.-C.F.)
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Yu-Hsiang Juan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.L.); (Y.-H.J.); (T.-C.F.)
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Tieh-Cheng Fu
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.L.); (Y.-H.J.); (T.-C.F.)
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung 204, Taiwan
| | - Chi-Chun Lai
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (Y.-C.L.); (Y.-H.J.); (T.-C.F.)
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung 204, Taiwan
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung 204, Taiwan
- Correspondence: (C.-C.L.); (H.-K.S.); (T.-F.T.); Tel.: +886-2-24313131 (ext. 6101) (C.-C.L.); +886-37-206166 (ext. 31010) (H.-K.S.); +886-2-28267293 (T.-F.T.)
| | - Huey-Kang Sytwu
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli 350, Taiwan
- National Defense Medical Center, Department & Graduate Institute of Microbiology and Immunology, Taipei 114, Taiwan
- Correspondence: (C.-C.L.); (H.-K.S.); (T.-F.T.); Tel.: +886-2-24313131 (ext. 6101) (C.-C.L.); +886-37-206166 (ext. 31010) (H.-K.S.); +886-2-28267293 (T.-F.T.)
| | - Ting-Fen Tsai
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli 350, Taiwan; (Y.-J.C.); (P.W.-C.H.); (S.-F.T.)
- Departments of Life Sciences and Institute of Genome Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Correspondence: (C.-C.L.); (H.-K.S.); (T.-F.T.); Tel.: +886-2-24313131 (ext. 6101) (C.-C.L.); +886-37-206166 (ext. 31010) (H.-K.S.); +886-2-28267293 (T.-F.T.)
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16
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Mital R, Bayne J, Rodriguez F, Ovbiagele B, Bhatt DL, Albert MA. Race and Ethnicity Considerations in Patients With Coronary Artery Disease and Stroke: JACC Focus Seminar 3/9. J Am Coll Cardiol 2021; 78:2483-2492. [PMID: 34886970 DOI: 10.1016/j.jacc.2021.05.051] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 05/18/2021] [Indexed: 01/29/2023]
Abstract
Notable racial and ethnic differences and disparities exist in coronary artery disease (CAD) and stroke epidemiology and outcomes despite substantial advances in these fields. Racial and ethnic minority subgroups remain underrepresented in population data and clinical trials contributing to incomplete understanding of these disparities. Differences in traditional cardiovascular risk factors such as hypertension and diabetes play a role; however, disparities in care provision and process, social determinants of health including socioeconomic position, neighborhood environment, sociocultural factors, and racial discrimination within and outside of the health care system also drive racial and ethnic CAD and stroke disparities. Improved culturally congruent and competent communication about risk factors and symptoms is also needed. Opportunities to achieve improved and equitable outcomes in CAD and stroke must be identified and pursued.
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Affiliation(s)
- Rohit Mital
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Joseph Bayne
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine, Stanford University, Stanford, California, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco, San Francisco, California, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle A Albert
- Center for the Study of Adversity and Cardiovascular Disease (NURTURE Center), Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
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17
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Tan JWC, Chew DP, Tsui KL, Tan D, Duplyakov D, Hammoudeh A, Zhang B, Li Y, Xu K, Ong PJ, Firman D, Gamra H, Almahmeed W, Dalal J, Tam LW, Steg G, Nguyen QN, Ako J, Al Suwaidi J, Chan M, Sobhy M, Shehab A, Buddhari W, Wang Z, Fong AYY, Karadag B, Kim BK, Baber U, Chin CT, Han YL. 2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y1 2 Receptor Antagonists in the Asia-Pacific Region: Special Populations. Eur Cardiol 2021; 16:e43. [PMID: 34815751 PMCID: PMC8591619 DOI: 10.15420/ecr.2021.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022] Open
Abstract
Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.
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Affiliation(s)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | - Kin Lam Tsui
- Pamela Youde Nethersole Eastern Hospital Hong Kong, China
| | - Doreen Tan
- Department of Pharmacy, Faculty of Science, National University of Singapore Singapore
| | | | | | - Bo Zhang
- Department of Cardiology, First Affiliated Hospital, Dalian Medical University Dalian, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | - Paul J Ong
- Heart Specialist International, Mount Elizabeth Novena Hospital Singapore.,Tan Tock Seng Hospital Singapore
| | - Doni Firman
- Harapan Kita National Cardiovascular Center/Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia Harapan Kita Jakarta, Indonesia
| | - Habib Gamra
- Cardiology Department, Fattouma Bourguiba University Hospital and University of Monastir Monastir, Tunisia
| | | | - Jamshed Dalal
- Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital Mumbai, India
| | | | - Gabriel Steg
- Department of Cardiology, Hôpital Bichat Paris, France
| | - Quang N Nguyen
- Department of Cardiology, Hanoi Medical University Hanoi, Vietnam
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine Sagamihara, Kanagawa, Japan
| | | | - Mark Chan
- National University Heart Centre Singapore
| | | | - Abdulla Shehab
- College of Medicine and Health Sciences, UAE University, Al Ain United Arab Emirates
| | | | - Zulu Wang
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | | | - Bilgehan Karadag
- Istanbul University-Cerrahpasa School of Medicine Istanbul, Turkey
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine Seoul, South Korea
| | - Usman Baber
- University of Oklahoma Health Sciences Center Oklahoma City, OK, US
| | | | - Ya Ling Han
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
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