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Mast L, Peeters MYM, Söhne M, Hackeng CM, Knibbe CAJ, van den Broek MPH. The effect of renal impairment and obesity on anti-Xa peak and trough levels in patients receiving therapeutic doses of nadroparin: a comparison with control patients. Eur J Clin Pharmacol 2023; 79:1537-1547. [PMID: 37707559 PMCID: PMC10618299 DOI: 10.1007/s00228-023-03558-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE Anti-Xa peak level monitoring is recommended during LMWH treatment in renal impairment or obesity. The trough level has been proposed as marker for bleeding. We studied the influence of renal impairment and obesity on anti-Xa levels. METHODS Peak and trough levels were collected during therapeutic nadroparin treatment in patients with renal impairment, obese patients, and controls. 27 patients (n = 68 samples) were evaluated and combined with published data (n = 319 samples from 35 patients) using population pharmacokinetic (popPK) modelling. RESULTS Median peak level was 0.44 and 0.95 IU/mL in renal impairment with and without dose reduction and 0.60 and 0.43 IU/mL in obesity and controls, respectively. Trough levels were < 0.5 IU/mL in all patients with renal impairment with dose reduction and in 5/6 control patients. In the popPK model, total body weight and eGFR were covariates for clearance and lean body weight for distribution volume. Model-based evaluations demonstrated peak levels below the therapeutic window in controls and increased levels in renal impairment. Dose reductions resulted in a different effect on peak and trough levels. Obese patients (BMI up to 32 kg/m2) had similar levels upon weight-based dosing. CONCLUSION In renal impairment, anti-Xa peak levels after dose reduction are comparable to those in controls. Weight-based dosing is suitable for obese patients. Aiming for peak levels between 0.6 and 1.0 IU/mL in these patients would result in overexposure compared to controls. Considering the association of trough levels and bleeding risk and our findings, trough monitoring seems to be a suitable parameter to identify nadroparin accumulation.
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Affiliation(s)
- L Mast
- Department of Clinical Pharmacy, Zaandam Medical Centre, Zaandam, The Netherlands
| | - M Y M Peeters
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M Söhne
- Department of Hematology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - C M Hackeng
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - C A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - M P H van den Broek
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
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2
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Vlot EA, Hackeng CM, Aper SJ, Sonker U, Heijmen RH, van Dongen EP, Noordzij PG. Does Intraoperative Fibrinogen Affect Blood Loss or Transfusion Practice After Aortic Arch Surgery: A Prematurely Ended Randomized Trial. Clin Appl Thromb Hemost 2022; 28:10760296221144042. [PMID: 36476152 PMCID: PMC9742581 DOI: 10.1177/10760296221144042] [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] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular surgery is often complicated by significant bleeding due to perioperative coagulopathy. The effectiveness of treatment with fibrinogen concentrate to reduce the perioperative blood transfusion rate after thoracic aortic replacement surgery in prior studies has shown conflicting results. Therefore, we conducted a double-blind randomized controlled trial to investigate if a single dose of intraoperative fibrinogen administration reduced blood loss and allogeneic transfusion rate after elective surgery for thoracic arch aneurysm with deep hypothermic circulatory arrest. Twenty patients were randomized to fibrinogen concentrate (N = 10) or placebo (N = 10). The recruitment of study patients was prematurely ended due to a low inclusion rate. Perioperative transfusion, 5-minute bleeding mass after study medication and postoperative blood loss were not different between the groups with fibrinogen concentrate or placebo. Due to small volumes of postoperative blood loss and premature study termination, a beneficial effect of fibrinogen concentrate on the number of blood transfusions could not be established. However, treatment with fibrinogen efficiently restored fibrinogen levels and clot strength to preoperative values with a more effective preserved postoperative thrombin generation capacity. This result might serve as a pilot for further multicenter studies to assess the prospective significance of automated and standardized thrombin generation as a routine assay for monitoring perioperative coagulopathy and its impact on short- and long-term operative results.
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Affiliation(s)
- Eline A. Vlot
- Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands,Eline A. Vlot, Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, Netherlands.
| | - Christian M. Hackeng
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Stijn J.A. Aper
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Uday Sonker
- Department of Cardiac Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Robin H. Heijmen
- Department of Cardiac Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Eric P.A. van Dongen
- Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Peter G. Noordzij
- Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
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3
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Willemsen LM, Vlot EA, Janssen PWA, Visser CD, Zheng K, Kelder JC, Noordzij PG, van den Dool E, Klein P, Hackeng CM, ten Berg JM. Blood loss after coronary artery bypass by aspirin responsiveness assessed with preoperative VerifyNow aspirin testing. Res Pract Thromb Haemost 2021; 5:e12623. [PMID: 34993386 PMCID: PMC8713006 DOI: 10.1002/rth2.12623] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/01/2021] [Accepted: 10/09/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Aspirin is important for preventing thrombotic events but also increases bleeding complications. Minimizing bleeding while preventing thrombotic events remains challenging in patients undergoing coronary artery bypass grafting (CABG). Establishing the patient's preoperative aspirin response could distinguish patients at risk for perioperative blood loss. OBJECTIVE Aim was to compare 12-h blood loss after CABG between aspirin-sensitive and aspirin-resistant patients. PATIENTS/METHODS The primary analysis of this substudy of the POPular CABG trial (NCT02352402) included patients that used aspirin monotherapy preoperatively. A preoperative platelet function test by the VerifyNow aspirin assay was performed before CABG and patients were classified as aspirin-sensitive or aspirin-resistant based on an aspirin reaction units cutoff value of 550. The primary end point was 12-hour blood loss after CABG. The secondary end point was, among others, clinical bleeding events after CABG. RESULTS A total of 128 patients were included in the primary analysis. Of these, 116 patients were aspirin sensitive and 12 were aspirin resistant. Mean blood loss 12 hours after CABG was 555 ± 278 mL in aspirin-sensitive patients and 406±110 mL in aspirin-resistant patients (P = .04). All bleeding events (n = 15; 11.7%) occurred in aspirin-sensitive patients. CONCLUSIONS In patients who are on aspirin preoperatively, aspirin sensitivity was associated with 12-hour blood loss after CABG, suggesting that preoperative VerifyNow aspirin testing could identify patients undergoing CABG at high risk for perioperative bleeding.
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Affiliation(s)
| | - Eline A. Vlot
- Department of Anesthesiology, Intensive Care, and Pain MedicineSt Antonius HospitalNieuwegeinThe Netherlands
| | | | - Claire D. Visser
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
| | - Kai Zheng
- Department of CardiologySt Antonius HospitalNieuwegeinThe Netherlands
| | | | - Peter G. Noordzij
- Department of Anesthesiology, Intensive Care, and Pain MedicineSt Antonius HospitalNieuwegeinThe Netherlands
| | | | - Patrick Klein
- Department of Cardiothoracic SurgerySt Antonius HospitalNieuwegeinThe Netherlands
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4
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Vlot EA, van Dongen EPA, Willemsen LM, Berg JMT, Hackeng CM, Loer SA, Noordzij PG. Association of Plasma Fibrinogen and Thromboelastography With Blood Loss in Complex Cardiac Surgery. Clin Appl Thromb Hemost 2021; 27:10760296211016541. [PMID: 34013768 PMCID: PMC8142233 DOI: 10.1177/10760296211016541] [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] [Indexed: 11/16/2022] Open
Abstract
Postoperative coagulopathic bleeding is common in cardiac surgery and is
associated with increased morbidity and mortality. Ideally, real-time
information on in-vivo coagulation should be available. However, up to now it is
unclear which perioperative coagulation parameters can be used best to
accurately identify patients at increased risk of bleeding. The present study
analyzed the associations of perioperative fibrinogen concentrations and whole
blood viscoelastic tests with postoperative bleeding in 89 patients undergoing
combined cardiac surgery procedures. Postoperative bleeding was recorded until
24 hours after surgery. Regression analyses were performed to establish
associations between blood loss and coagulation parameters after cardiopulmonary
bypass including a prediction model with known confounding factors for bleeding.
Coagulation tests show large changes over the perioperative course with the
strongest coagulopathic deviations from baseline after cardiopulmonary bypass.
After adjustment for multiple confounders, viscoelastic clot strength instead of
fibrinogen concentration showed a similar performance for 24 hour blood loss and
a better performance for 6 hour blood loss. This makes intraoperative
viscoelastic testing a useful tool to strengthen early clinical decision-making
with the potential to reduce perioperative blood transfusions.
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Affiliation(s)
- Eline A Vlot
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric P A van Dongen
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jur M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christian M Hackeng
- Department of Clinical Chemistry, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Stephan A Loer
- Department of Anaesthesia, Intensive Care and Pain Medicine, Amsterdam UMC, The Netherlands
| | - Peter G Noordzij
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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5
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Zheng KL, Wallen H, Aradi D, Godschalk TC, Hackeng CM, Dahlen JR, Ten Berg JM. The Total Thrombus Formation (T-TAS) platelet (PL) assay, a novel test that evaluates whole blood platelet thrombus formation under physiological conditions. Platelets 2021; 33:273-277. [PMID: 33554695 DOI: 10.1080/09537104.2021.1882669] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Dual antiplatelet therapy (DAPT, aspirin, and a P2Y12 inhibitor) reduces thrombotic events in patients with coronary artery disease (CAD). The T-TAS PL assay uses arterial shear flow over collagen surface, better mimicking in vivo conditions compared to conventional agonist-based platelet function assays, to evaluate platelet function. Here, the platelet function in patients taking DAPT is evaluated with the T-TAS PL assay. In 57 patients with CAD, taking DAPT ≥7 days (n = 22 for clopidogrel, n = 15 for prasugrel, n = 20 for ticagrelor), T-TAS PL assessments were performed in duplicate, and expressed as area under the flow pressure curve within a 10-minute period (AUC10). The duplicate measurements were strongly correlated (r = 0.90, p < .001), with an intra-assay coefficient of variation (CV) of 11,5%. For clopidogrel, the median AUC10 was 11.5 (IQR5.9-41.8), for prasugrel 28.8 (IQR10.3-37.6), and for ticagrelor 8.9 (IQR 6.4-10.9). All measurements were below the AUC10 cutoff of 260 measured in healthy volunteers, suggesting excellent discrimination of DAPT-treated and untreated persons. The new T-TAS PL assay demonstrated complete discrimination of platelet function in patients on DAPT based on an established cutoff. Ticagrelor showed lower levels of platelet function and a more uniform response compared to prasugrel and clopidogrel.
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Affiliation(s)
- K L Zheng
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - H Wallen
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - D Aradi
- Department of Cardiology, Heart Center Balatonfüred, and Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - T C Godschalk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - C M Hackeng
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | | | - J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
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6
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Vlot EA, Van den Dool EJ, Hackeng CM, Sohne M, Noordzij PG, Van Dongen EPA. Anti Xa activity after high dose LMWH thrombosis prophylaxis in covid 19 patients at the intensive care unit. Thromb Res 2020; 196:1-3. [PMID: 32805623 PMCID: PMC7374121 DOI: 10.1016/j.thromres.2020.07.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 05/02/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Coagulopathy in Coronavirus disease 2019 (covid-19) has been demonstrated by an increase in D-dimer, prothrombin time (PT), fibrinogen and factor VIII. Venous thromboembolic events are a common abnormality in patients with covid-19. We evaluate the results of intensive care unit (ICU) thrombosis prophylaxis of 5700 international unit (IU) nadroparin low molecular weight heparin (LMWH) twice daily. METHODS After introduction of this high-dose pharmacological thrombosis prophylaxis twice weekly anti-factor Xa (anti Xa) concentrations and results from routine laboratory and viscoelastic hemostatic tests in 16 ICU covid-19 patients were evaluated. RESULTS During one week, median peak anti Xa activities were 0.38 [0.16-0.45] and 0.38 [0.20-0.58] at time point 1 and 2 respectively. Laboratory coagulation tests showed PT, AT and platelet count (PltC) values within normal range and markedly increased D-dimer and fibrinogen levels. Viscoelastic tests showed a maximum clot strength just above normal reference value, while fibrin clot strength was strongly increased. The overall contribution of fibrin to clot strength was high with 71 [56-85]%. CONCLUSION Anti Xa activity was within the target range of pharmacodynamic endpoint for covid-19 patients but viscoelastic tests still demonstrated a procoagulant pattern.
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Affiliation(s)
- E A Vlot
- Department of Anesthesiology, Intensive Care and Pain medicine, St Antonius Hospital, the Netherlands.
| | - E J Van den Dool
- Department of Clinical Chemistry, St Antonius Hospital, the Netherlands
| | - C M Hackeng
- Department of Clinical Chemistry, St Antonius Hospital, the Netherlands
| | - M Sohne
- Department of Hematology, St Antonius Hospital, the Netherlands
| | - P G Noordzij
- Department of Anesthesiology, Intensive Care and Pain medicine, St Antonius Hospital, the Netherlands
| | - E P A Van Dongen
- Department of Anesthesiology, Intensive Care and Pain medicine, St Antonius Hospital, the Netherlands
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7
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Munnix ICA, Van Oerle R, Verhezen P, Kuijper P, Hackeng CM, Hopman-Kerkhoff HIJ, Hudig F, Van De Kerkhof D, Leyte A, De Maat MPM, Oude Elferink RFM, Ruinemans-Koerts J, Schoorl M, Slomp J, Soons H, Stroobants A, Van Wijk E, Henskens YMC. Harmonizing light transmission aggregometry in the Netherlands by implementation of the SSC-ISTH guideline. Platelets 2020; 32:516-523. [PMID: 32522065 DOI: 10.1080/09537104.2020.1771549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Light transmission aggregometry (LTA) is considered the gold standard method for evaluation of platelet function. However, there are a lot of variation in protocols (pre-analytical procedures and agonist concentrations) and results. The aim of our study was to establish a national LTA protocol, to investigate the effect of standardization and to define national reference values for LTA. The SSC guideline was used as base for a national procedure. Almost all recommendations of the SSC were followed e.g. no adjustment of PRP, citrate concentration of 109 mM, 21 needle gauge, fasting, resting time for whole blood and PRP, centrifugation time, speed and agonists concentrations. LTA of healthy volunteers was measured in a total of 16 hospitals with 5 hospitals before and after standardization. Results of more than 120 healthy volunteers (maximum aggregation %) were collected, with participating laboratories using 4 different analyzers with different reagents. Use of low agonist concentrations showed high variation before and after standardization, with the exception of collagen. For most high agonist concentrations (ADP, collagen, ristocetin, epinephrine and arachidonic acid) variability in healthy subjects decreased after standardization. We can conclude that a standardized Dutch protocol for LTA, based on the SSC guideline, does not result in smaller variability in healthy volunteers for all agonist concentrations.
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Affiliation(s)
- I C A Munnix
- Department of Clinical Chemistry, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - R Van Oerle
- Central Diagnostic Laboratory, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - P Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - P Kuijper
- Clinical Laboratory, Maxima Medical Centre, Veldhoven, The Netherlands
| | - C M Hackeng
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - F Hudig
- LabWest, Haga Teaching Hospital, The Hague, The Netherlands
| | - D Van De Kerkhof
- Clinical Laboratory, Catharina Hospital, Eindhoven, The Netherlands
| | - A Leyte
- Department of Clinical Chemistry, OLVG Laboratoria BV, Amsterdam, The Netherlands
| | - M P M De Maat
- Department of Hematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | - J Ruinemans-Koerts
- Department of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands
| | - M Schoorl
- Department of Clinical Chemistry, Haematology & Immunology,Northwest Clinics, Alkmaar, The Netherlands
| | - J Slomp
- Department of Clinical Chemistry, Medlon, Location Medisch Spectrum Twente, Enschede, The Netherlands
| | - H Soons
- Department of Clinical Chemistry, St. Anna Hospital, Geldrop, The Netherlands
| | - A Stroobants
- Department of Clinical Chemistry, AmsterdamUMC Location AMC, Amsterdam, The Netherlands
| | - E Van Wijk
- Department of Clinical Chemistry, St. Elisabeth Hospital, Tilburg, The Netherlands
| | - Y M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre +, Maastricht, The Netherlands
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8
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Janssen PWA, Bergmeijer TO, Vos GJA, Kelder JC, Qaderdan K, Godschalk TC, Breet NJ, Deneer VHM, Hackeng CM, Ten Berg JM. Tailored P2Y 12 inhibitor treatment in patients undergoing non-urgent PCI-the POPular Risk Score study. Eur J Clin Pharmacol 2019; 75:1201-1210. [PMID: 31197411 DOI: 10.1007/s00228-019-02696-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/06/2019] [Accepted: 05/17/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE The POPular Risk Score was developed for the selective intensification of P2Y12 inhibitor treatment with prasugrel instead of clopidogrel in patients undergoing non-urgent percutaneous coronary intervention (PCI) with stent implantation. This score is based on platelet reactivity (VerifyNow P2Y12 assay), CYP2C19 genotyping, and clinical risk factors. Our aim was to determine if the use of this score in clinical practice is associated with a reduction in thrombotic events without increasing bleeding events. METHODS In a single-center prospective cohort study, patients with a high risk score were treated with prasugrel and patients with a low risk score with clopidogrel. The risk score-guided cohort was compared with a historic cohort of clopidogrel-treated patients. The endpoint consisted of all-cause death, myocardial infarction, stroke, or stent thrombosis during 1 year of follow-up. TIMI major and minor bleeding events were also analyzed. RESULTS The guided cohort contained 1127 patients, 26.9% of whom were switched to prasugrel according to the POPular Risk Score. The historic cohort contained 893 patients. The incidence of the combined thrombotic endpoint was significantly lower in the guided cohort as compared with the historic cohort (8.4% versus 3.7%, p < 0.001). This strategy was safe with respect to bleeding (4.0% versus 1.3%, p < 0.001, for TIMI major or minor bleeding). Results were comparable after multivariate and propensity score matched and weighted analysis. CONCLUSION Selective intensification of P2Y12 inhibitor treatment after non-urgent PCI based on the POPular Risk Score is associated with a reduction in thrombotic events without an increase in bleeding events.
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Affiliation(s)
- Paul W A Janssen
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands. .,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.
| | - Thomas O Bergmeijer
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands.,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Gert-Jan A Vos
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands.,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes C Kelder
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands.,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Khalid Qaderdan
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands.,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Thea C Godschalk
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands.,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Nicoline J Breet
- St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, Gelre ziekenhuizen, Apeldoorn, The Netherlands
| | - Vera H M Deneer
- St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Christian M Hackeng
- St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Chemistry, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St Antonius Hospital, P/O Box 2500, 3432 EM, Nieuwegein, The Netherlands.,St Antonius Centre for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
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9
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Vlot EA, Willemsen LM, Van Dongen EPA, Janssen PW, Hackeng CM, Kloppenburg GTL, Kelder JC, Ten Berg JM, Noordzij PG. Perioperative point of care platelet function testing and postoperative blood loss in high-risk cardiac surgery patients. Platelets 2018; 30:982-988. [PMID: 30411659 DOI: 10.1080/09537104.2018.1542123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Postoperative coagulopathic bleeding is common in cardiac surgery and associated with increased morbidity and mortality. Platelet function is affected by multiple factors, including patient and procedural characteristics. Point-of-care (POC) multiple electrode aggregometry (MEA) can rapidly detect and quantify platelet dysfunction and could contribute to optimal patient blood management. In patients undergoing CABG and heart valve surgery platelet function was assessed using POC MEA at four different perioperative timepoints in response to stimulation with four specific receptor agonists (ADP, AA, COL, TRAP). Postoperative bleeding was recorded during 24 h after surgery. Regression analyses were performed to establish associations between perioperative platelet function and postoperative blood loss. Ninety-nine patients were included in the study. Fifty-nine patients (60%) were on antiplatelet therapy (APT) at time of surgery. ADP- and AA-induced platelet aggregation declined during CPB and after decannulation from CPB, with a maximum decrease of 55% for ADP (35 vs. 77 AU at baseline; P < 0.001) and 78% for ASPI (14 vs. 64 AU at baseline; P < 0.001). A linear relationship was present between ADP-induced platelet aggregometry at baseline and postoperative blood loss (r = -0.249; P = 0.015). In aspirin users, the maximum decline in platelet function between baseline and CPB decannulation was related to postoperative blood loss (r = 0.308; P = 0.037). In multivariate analysis, a reduced ADP platelet function prior to surgery remained associated with postoperative blood loss (r = -0.239; P = 0.012). Reduced ADP-induced platelet aggregation at baseline is associated with increased postoperative blood loss in high-risk cardiac surgery patients.
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Affiliation(s)
- Eline A Vlot
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Eric P A Van Dongen
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Paul W Janssen
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Christian M Hackeng
- Department of Clinical Chemistry, St Antonius Hospital , Nieuwegein , The Netherlands
| | | | - Johannes C Kelder
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital , Nieuwegein , The Netherlands
| | - Peter G Noordzij
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital , Nieuwegein , The Netherlands
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10
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Godschalk TC, Willemsen LM, Zwart B, Bergmeijer TO, Janssen PWA, Kelder JC, Hackeng CM, ten Berg JM. Effect of Tailored Antiplatelet Therapy to Reduce Recurrent Stent Thrombosis and Cardiac Death After a First Episode of Stent Thrombosis. Am J Cardiol 2017; 119:1500-1506. [PMID: 28318511 DOI: 10.1016/j.amjcard.2017.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
The recurrence rate of coronary stent thrombosis (ST) is high. Patients with ST often demonstrate high on-treatment platelet reactivity (HPR). It is suggested that patients at high risk of atherothrombotic events, that is patients with ST, could benefit from tailored antiplatelet therapy (APT). This study evaluated whether tailored APT, based on platelet function testing, reduced the rate of cardiac death and/or recurrent ST at 1 year after ST, compared with a historical cohort of patients with ST without tailored APT. Patients with definite ST visited our ST outpatient clinic for platelet function testing and tailored APT. These patients were evenly matched to a historical cohort of patients with ST treated with aspirin and clopidogrel, which was the standard of care at that time. The primary end point was a composite of cardiac death and/or recurrent definite ST after 1 year. In total, 113 patients who visited the outpatient clinic were included. HPR was observed in 46%, 6.7%, and 0% of the patients on clopidogrel, prasugrel, and ticagrelor, respectively. After tailored APT, 93% of the patients with HPR demonstrated normal platelet reactivity. The primary end point was observed in 4 patients who had visited the outpatient clinic and in 23 patients of the historical cohort. The odds ratio of tailored APT on the primary end point was 0.26 (95% confidence interval 0.11 to 0.64, p = 0.003), independent from the possible confounders prior myocardial infarction and stent type. In conclusion, the outpatient ST clinic was associated with lower HPR rates in patients with ST after tailored APT. Patients who visited the ST outpatient clinic had a lower risk for cardiac death and/or recurrent ST compared with a historical cohort of patients with ST without tailored APT. Regarding the high HPR rate in patients with ST on clopidogrel, these patients might benefit in particular from the strategy of tailored APT.
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Bergmeijer TO, Godschalk TC, Janssen PWA, Berge KVD, Breet NJ, Kelder JC, Hackeng CM, Ten Berg JM. How Long Does It Take for Clopidogrel and Ticagrelor to Inhibit Platelets in Patients Undergoing Primary Percutaneous Coronary Intervention? A Detailed Pharmacodynamic Analysis: Time Course of Platelet Reactivity in STEMI (TOPS). Semin Thromb Hemost 2017; 43:439-446. [PMID: 28561235 DOI: 10.1055/s-0037-1599156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Antiplatelet therapy plays a pivotal role in patients with an ST-segment elevation myocardial infarction (STEMI) to prevent further atherothrombotic events, such as stent thrombosis. Although the risk of stent thrombosis is highest in the first hours after primary percutaneous coronary intervention (pPCI), little is known about when an adequate level of platelet inhibition is achieved following a clopidogrel or ticagrelor loading dose in STEMI patients. Patients presenting with STEMI in whom pPCI was performed and who were loaded with 600 mg clopidogrel or 180 mg ticagrelor were eligible for enrolment in this nonrandomized, open label, single-center study. Platelet reactivity was measured before PCI, 6 and 24 hours after loading dose and after 2, 7, and 14 days, using the VerifyNow P2Y12 assay as well as 20 µmol/L adenosine diphosphate stimulated light transmittance aggregometry (LTA). We analyzed the time until a VerifyNow result of < 236 P2Y12 reaction units or LTA maximum platelet aggregation of < 64.5% was reached. A total of 28 patients were participated in this study. Platelet reactivity dropped below the high platelet reactivity cutoff level after 11.4 (VerifyNow) and 5.7 (LTA) hours in patients who were loaded with clopidogrel, and after 2.4 (VerifyNow) and 3.9 (LTA) hours in patients who were loaded with ticagrelor. Despite the administration of a clopidogrel or ticagrelor loading dose, it still takes multiple hours (2-11) to reach adequate platelet inhibition in STEMI patients. This might indicate the need for additional antiplatelet therapy in the first hours after loading in patients undergoing pPCI with stenting.
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Affiliation(s)
- Thomas O Bergmeijer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Thea C Godschalk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Paul W A Janssen
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Kim van den Berge
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Nicoline J Breet
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Johannes C Kelder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
| | - Christian M Hackeng
- St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands.,Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,St. Antonius Center for Platelet Function Research, Nieuwegein, The Netherlands
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12
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Janssen PWA, Bergmeijer TO, Godschalk TC, Le TTD, Breet NJ, Kelder JC, Hackeng CM, Ten Berg JM. The effect of correcting VerifyNow P2Y12 assay results for hematocrit in patients undergoing percutaneous coronary interventions. J Thromb Haemost 2017; 15:618-623. [PMID: 28135786 DOI: 10.1111/jth.13642] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Indexed: 12/12/2022]
Abstract
Essentials Platelet reactivity is correlated with thrombotic risk after percutaneous coronary intervention (PCI). Hematocrit (HCT) is associated with platelet reactivity as measured with the VerifyNow P2Y12 assay. We tested a formula proposed to correct VerifyNow measurements for HCT in 978 PCI patients. Correcting platelet reactivity for HCT did not improve the prediction of thrombotic events after PCI. SUMMARY Background High on-treatment platelet reactivity is predictive for the occurrence of atherothrombotic events following percutaneous coronary interventions (PCIs). A low hematocrit (HCT) value is associated with higher platelet reactivity values, expressed in P2Y12 reaction units (PRU), as measured with the VerifyNow P2Y12 assay. However, it is suggested that this is only an in vitro phenomenon. Objective To determine whether adjusting PRU for HCT improves the predictive value for thrombotic events following PCI. Material and methods The VerifyNow P2Y12 assay was performed in clopidogrel-treated patients undergoing non-urgent PCI included in a prospective cohort study. PRU values were corrected for HCT with a formula proposed in recent literature. Receiver operating characteristic (ROC) curves were made to determine the optimal cut-off values to predict the occurrence of the primary endpoint, a composite of all-cause death and non-fatal myocardial infarction, stent thrombosis and ischemic stroke, during 1 year of follow-up. The chi-squared test was performed to determine whether correcting PRU for HCT improved the prediction of the primary endpoint. Results A total of 978 patients were analyzed. A negative correlation between PRU and HCT was observed (R2 = 0.104). The optimal cut-off value for the corrected PRU was 215. ROC analyses showed that prediction of the primary endpoint did not differ for the corrected PRU (area under the curve, 0.61; sensitivity, 0.57; specificity, 0.64) and the uncorrected PRU (area under the curve, 0.61; sensitivity, 0.69; specificity, 0.53). Conclusion Correcting PRU for HCT does not improve the prediction of thrombotic events following PCI.
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Affiliation(s)
- P W A Janssen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
| | - T O Bergmeijer
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
| | - T C Godschalk
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
| | - T T D Le
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
| | - N J Breet
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
| | - J C Kelder
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - C M Hackeng
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Clinical Chemistry, St Antonius Hospital, Nieuwegein, the Netherlands
| | - J M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
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13
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Vlot EA, Meents N, van de Garde EM, Hackeng CM, Noordzij PG. Early Point-of-Care Platelet Function Testing Using Multiple Electrode Aggregometry in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:e56-e58. [DOI: 10.1053/j.jvca.2016.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Indexed: 11/11/2022]
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14
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Loeffen R, Godschalk TC, van Oerle R, Spronk HMH, Hackeng CM, ten Berg JM, ten Cate H. The hypercoagulable profile of patients with stent thrombosis. Heart 2015; 101:1126-32. [PMID: 25999588 PMCID: PMC4515992 DOI: 10.1136/heartjnl-2014-306685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/05/2015] [Indexed: 01/10/2023] Open
Abstract
Objective Coronary stent thrombosis is a devastating complication after percutaneous coronary intervention (PCI). The mechanisms underlying stent thrombosis are multifactorial. Whether the coagulation system is involved in the pathophysiology of stent thrombosis is unclear. We hypothesised that thrombin generation, reflecting the coagulation potential, is enhanced in patients with stent thrombosis. Methods A case–control study was performed, including 63 patients with PCI: 23 cases (stent thrombosis) and 40 controls (no stent thrombosis). Thrombin generation was measured using 0, 1 and 5 pM tissue factor (TF) triggers. Active site-inhibited factor VIIa (ASIS) and recombinant thrombomodulin were added to study the contact activation system and the protein C pathway, respectively. Results Thrombin generation was significantly increased for all TF triggers in cases compared with controls. Addition of ASIS to the measurement without exogenous TF revealed significantly enhanced contact activation in cases compared with controls; mean peak height: 241 vs 183 nM. Thrombin generation was also significantly increased in cases compared with controls in the presence of exogenous TF; mean peak height: 263 vs 233 nM (5 pM TF). Addition of thrombomodulin reduced thrombin generation by 23% in cases and 31% in controls (p<0.018), suggesting alterations in the protein C pathway in cases. Conclusions This is the first study that suggests the involvement of the coagulation system in stent thrombosis. Stent thrombosis patients showed a hypercoagulable state, most likely caused by enhanced contact activation and attenuation of anticoagulation by the protein C pathway.
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Affiliation(s)
- R Loeffen
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - T C Godschalk
- Department of Cardiology, St. Antonius Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R van Oerle
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H M H Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - C M Hackeng
- Department of Clinical Chemistry, St. Antonius Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J M ten Berg
- Department of Cardiology, St. Antonius Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - H ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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15
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Diepstraten J, Janssen EJH, Hackeng CM, van Dongen EPA, Wiezer RJ, van Ramshorst B, Knibbe CAJ. Population pharmacodynamic model for low molecular weight heparin nadroparin in morbidly obese and non-obese patients using anti-Xa levels as endpoint. Eur J Clin Pharmacol 2014; 71:25-34. [DOI: 10.1007/s00228-014-1760-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/19/2014] [Indexed: 11/24/2022]
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16
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Janssen PW, ten Berg JM, Hackeng CM. The use of platelet function testing in PCI and CABG patients. Blood Rev 2014; 28:109-21. [DOI: 10.1016/j.blre.2014.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 03/11/2014] [Indexed: 11/27/2022]
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17
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Van Der Heyden J, Van Werkum J, Hackeng CM, Kelder JC, Breet NJ, Deneer VHM, Ackerstaff RGA, Tromp SC, De Vries JPPM, Vos JA, Suttorp MJ, Elsenberg EHA, Van Neerven D, Schonewille WJ, Wolters F, Ten Berg JM. High versus standard clopidogrel loading in patients undergoing carotid artery stenting prior to cardiac surgery to assess the number of microemboli detected with transcranial Doppler: results of the randomized IMPACT trial. J Cardiovasc Surg (Torino) 2013; 54:337-347. [PMID: 23138609] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
AIM The aim of this study was to compare the effects of 300 mg or 600 mg clopidogrel loading dose, prior to carotid artery stenting (CAS) on the number of transcranial Doppler (TCD)-detected microembolic signals (MES) and to investigate the relationship between the magnitude of platelet reactivity and MES. METHODS In this prospective randomized, double-blind study, 35 consecutive asymptomatic patients (17.1% females), scheduled for CAS and cardiac surgery were included. The primary endpoint was the number of TCD-detected MES. The secondary endpoints were the absolute magnitude of on-treatment platelet reactivity and the adverse cerebral events. Negative binomial regression to find predictors for sum of single emboli, the student's t-test to assess the association between platelet function tests and randomized dose of 300 mg or 600 mg clopidogrel, and the R2 calculation for the assessment of the association between platelet function tests and embolic load, were used. RESULTS No statistically significant difference in the number of TCD-detected MES, in the sum of all the single emboli or showers and platelet aggregation measurements between the two groups was observed (aggregometry: 21.7±18.3 versus 23±18%, P=0.8499 and 45.8±17.5 versus 46.5±14.5%, P=0.9003) (verifyNow P2Y12 assay: 231±93 PRU versus 222±86 PRU, P=0.7704). In one patient a transient ischemic attack occurred. CONCLUSION A loading dose of 300 mg of clopidogrel in combination with aspirin is as effective as 600 mg of clopidogrel in achieving adequate platelet inhibition and preventing periprocedural events in asymptomatic patients undergoing CAS prior to cardiac surgery.
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Affiliation(s)
- J Van Der Heyden
- Department of Interventional Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.
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Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Harmsze AM, Hackeng CM, ten Berg JM. The Authors' reply. Heart 2012. [DOI: 10.1136/heartjnl-2011-301435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Diepstraten J, Hackeng CM, van Kralingen S, Zapletal J, van Dongen EPA, Wiezer RJ, van Ramshorst B, Knibbe CAJ. Anti-Xa Levels 4 h After Subcutaneous Administration of 5,700 IU Nadroparin Strongly Correlate with Lean Body Weight in Morbidly Obese Patients. Obes Surg 2012; 22:791-796. [PMID: 22302439 DOI: 10.1007/s11695-012-0602-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND: Morbidly obese patients (BMI > 40 kg/m(2)) are at increased risk for venous thromboembolism, especially after surgery. Despite limited evidence, morbidly obese patients are often administered a double dose of nadroparin for thromboprophylaxis compared to non-obese patients. The aim of this study was to evaluate the influence of different body size descriptors on anti-Xa levels after a double dose of nadroparin (5,700 IU) in morbidly obese patients. METHODS: In 27 morbidly obese patients with a mean total body weight of 148 kg (range 107-260 kg), anti-Xa levels were determined peri-operatively until 24 h after administration of a subcutaneous dose of 5,700 IU of nadroparin. RESULTS: Anti-Xa level 4 h after administration (A(4h), mean 0.22 ± 0.07 IU/ml) negatively correlated strongly with lean body weight (r = -0.66 (p < 0.001)) and moderately with total body weight (r = -0.56 (p = 0.003)) and did not correlate with body mass index (r = -0.26 (p = 0.187)). The area under the anti-Xa level-time curve from 0 to 24 h (AUA(0-24h), mean 2.80 ± 0.97 h IU/ml) correlated with lean body weight (r = -0.63 (p = 0.007)), but did not correlate with total body weight (r = -0.44 (p = 0.075)) or body mass index (r = -0.10 (p = 0.709)). CONCLUCIONS: Following a subcutaneous dose of nadroparin 5,700 IU, A(4h) and AUA(0-24h) were found to negatively correlate strongly with lean body weight. From these results, individualized dosing of nadroparin based on lean body weight should be considered in morbidly obese patients.
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Affiliation(s)
- Jeroen Diepstraten
- Department of Clinical Pharmacy, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, Netherlands
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20
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Bouman HJ, van Werkum JW, Rudež G, Hackeng CM, Leebeek FWG, ten Cate H, ten Berg JM, de Maat MPM. The relevance of P2Y(12)-receptor gene variation for the outcome of clopidogrel-treated patients undergoing elective coronary stent implantation: a clinical follow-up. Thromb Haemost 2011; 107:189-91. [PMID: 22159428 DOI: 10.1160/th11-05-0306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 10/14/2011] [Indexed: 01/02/2023]
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21
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Harmsze AM, van Werkum JW, Souverein PC, Breet NJ, Bouman HJ, Hackeng CM, Ruven HJT, ten Berg JM, Klungel OH, de Boer A, Deneer VHM. Combined influence of proton-pump inhibitors, calcium-channel blockers and CYP2C19*2 on on-treatment platelet reactivity and on the occurrence of atherothrombotic events after percutaneous coronary intervention. J Thromb Haemost 2011; 9:1892-901. [PMID: 21854540 DOI: 10.1111/j.1538-7836.2011.04483.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The carriage of CYP2C19*2 and the use of proton-pump inhibitors (PPIs) and calcium-channel blockers (CCBs) has been associated with the diminished efficacy of clopidogrel. However, previous studies have only assessed the isolated impact of these risk factors for clopidogrel poor response. OBJECTIVES The aim of the present study was to investigate the impact of the combined presence of three risk factors for clopidogrel poor response, that is, the use of CCBs, PPIs and the carriage of CYP2C19*2, on on-treatment platelet reactivity and the occurrence of atherothrombotic events in 725 patients on dual antiplatelet therapy undergoing elective coronary stenting. METHODS In a prospective, follow-up study, on-treatment platelet reactivity was quantified using ADP-induced light transmittance aggregometry (LTA) and the VerifyNow P2Y12 assay. The clinical study endpoint was the composite of all-cause mortality, myocardial infarction, stent thrombosis and stroke at 1 year after stenting. RESULTS Patients with either one or more than one risk factor exhibited increased platelet reactivity (mean relative increase one risk factor: 11% and > 1 risk factor: 22%, respectively). Sixty-four events occurred during follow-up (8.8% of the study population). Patients with one risk factor for clopidogrel poor response did not have an increased risk of the composite endpoint. However, patients using both CCBs and PPIs and carriers of CYP2C19*2 who used CCBs had a statistically significant increased risk of the composite endpoint [hazard ratio(HR)(adj) 2.2 95% CI, 1.0-5.3, P = 0.044 and HR(adj) 3.3 95% CI, 1.1-9.8, P = 0.032, respectively]. CONCLUSIONS The presence of more than one of the three investigated risk factors for clopidogrel poor response is associated with an increased risk of adverse cardiovascular events within 1 year after elective coronary stenting.
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Affiliation(s)
- A M Harmsze
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, the Netherlands
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Bouman HJ, Schömig E, van Werkum JW, Velder J, Hackeng CM, Hirschhäuser C, Waldmann C, Schmalz HG, ten Berg JM, Taubert D. Reply to: "Paraoxonase-1 and clopidogrel efficacy". Nat Med 2011. [DOI: 10.1038/nm.2469] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Hackeng CM, ten Berg JM. The relationship between platelet reactivity and infarct-related artery patency in patients presenting with a ST-elevation myocardial infarction. Thromb Haemost 2011; 106:331-6. [PMID: 21713320 DOI: 10.1160/th10-08-0528] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Accepted: 11/25/2010] [Indexed: 11/05/2022]
Abstract
Both heightened platelet reactivity and an occluded infarct related artery (IRA) on initial angiography and at the time of primary percutaneous coronary intervention (PCI) are associated with a worsened clinical outcome in patients with ST-elevation myocardial infarction (STEMI). However, the relationship between platelet reactivity and IRA patency has not yet been established. Consecutive STEMI-patients were enrolled in this study. Patients who had TIMI-flow (thrombolysis in myocardial infarction) 0 or 1 on initial angiography constituted the occluded IRA group and patients having TIMI-flow 2 or 3 comprised the IRA patent group. Platelet function measurements were performed using the PFA-100 COL/ADP cartridge and light transmittance aggregometry without agonist (spontaneous) and after stimulation with adenosine diphosphate (ADP) and arachidonic acid (AA). Ninety-nine patients were enrolled, of whom 49 presented with an occluded IRA. Multivariate analysis identified the following independent factors to be associated with an occluded IRA; short COL/ADP closure time (ORper quartile increase=0.60; 95% CI, 0.39-.93; p=0.02), the 20 μM ADP-induced light transmittance aggregometry (ORper quartile increase =1.77; 95% CI, 1.15-2.73; p=0.01) and leukocyte counts (odds ratio [OR]=1.21; 95% CI, 1.05-1.39; p = 0.008). In conclusion, heightened platelet reactivity and elevated leukocyte counts are associated with an occluded IRA upon presentation in STEMI-patients. These results emphasise the importance of potent antithrombotic therapy early after the onset of symptoms, to obtain early recanalisation of the IRA.
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Affiliation(s)
- Nicoline J Breet
- St. Antonius Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, the Netherlands
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Bouman HJ, van Werkum JW, Breet NJ, ten Cate H, Hackeng CM, ten Berg JM. A case-control study on platelet reactivity in patients with coronary stent thrombosis. J Thromb Haemost 2011; 9:909-16. [PMID: 21382172 DOI: 10.1111/j.1538-7836.2011.04255.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The pathophysiology of stent thrombosis (ST) has evolved from the identification of single causative factors to a complex multifactorial model. OBJECTIVES The aim of the present study was to investigate whether patients with a history of ST exhibit heightened platelet reactivity to clopidogrel and aspirin. PATIENTS/METHODS Pretreatment and on-treatment platelet reactivity to clopidogrel and aspirin, as well as dual antiplatelet therapy resistance, was determined in 84 patients with a history of definite ST (cases: 41 early ST; 43 late ST) and in 103 control patients with a previously implanted coronary stent but no ST after the index procedure. Platelet function was evaluated with optical aggregometry, the VerifyNow P2Y12 and aspirin assays, the PFA-100 Innovance P2Y* cartridge, the flow cytometric vasodilator-stimulated phosphoprotein assay and urine 11-dehydrothromboxane B(2) measurement before and after the administration of a 600-mg loading dose of clopidogrel and 100 mg of aspirin. The study was registered at ClinicalTrials.gov, number NCT01012544. RESULTS Patients with a history of early ST clearly demonstrated higher on-clopidogrel platelet reactivity than controls. Patients with both early and late ST exhibited heightened on-aspirin platelet reactivity status, and dual antiplatelet therapy resistance was more frequent. CONCLUSIONS Patients with a history of early ST exhibit a poor response to clopidogrel. Furthermore, both early and late ST are strongly and independently associated with heightened on-aspirin platelet reactivity, and dual antiplatelet therapy resistance is more frequent.
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Affiliation(s)
- H J Bouman
- St Antonius Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands
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Harmsze AM, van Werkum JW, Taubert D, Hackeng CM, Deneer VHM. Esomeprazole but not pantoprazole is associated with lower plasma concentrations of clopidogrel's active metabolite. Ann Pharmacother 2011; 45:542-3. [PMID: 21487078 DOI: 10.1345/aph.1p425] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Harmsze AM, Hackeng CM, ten Berg JM. High on-treatment platelet reactivity to both aspirin and clopidogrel is associated with the highest risk of adverse events following percutaneous coronary intervention. Heart 2011; 97:983-90. [PMID: 21478385 DOI: 10.1136/hrt.2010.220491] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIM High on-clopidogrel platelet reactivity (HCPR) and high on-aspirin platelet reactivity (HAPR) are associated with atherothrombotic events following coronary stenting. There are, however, few data concerning high on-treatment platelet reactivity to both aspirin and clopidogrel simultaneously. The aim of the present study was to determine the incidence of dual high on-treatment platelet reactivity (DAPR) and its impact on clinical outcome. METHODS On-treatment platelet reactivity was measured in parallel by ADP- and arachidonic acid-induced light transmittance aggregometry (LTA) (n=921) and the point-of-care VerifyNow system (P2Y12 and aspirin) (n=422) in patients on dual antiplatelet therapy undergoing elective stent implantation. HCPR and HAPR were established by receiver-operator characteristic curve analysis. The primary endpoint was a composite of all-cause death, non-fatal acute myocardial infarction, stent thrombosis and ischaemic stroke at 1-year follow-up. RESULTS The incidence of DAPR varied between 14.7% and 26.9% depending on the platelet function test used. DAPR, assessed by LTA and the VerifyNow system, was highly associated with an adverse clinical outcome. At 1-year follow-up the primary endpoint occurred more frequently in patients with isolated HCPR (11.7%), isolated HAPR (9.6%) or DAPR (10.7%) compared with patients without high on-treatment platelet reactivity (4.2%, all p<0.01) when platelet function was evaluated with LTA. Using the VerifyNow system, patients exhibiting DAPR had the highest risk for the primary endpoint (17.7% vs 4.1% in patients without high on-treatment platelet reactivity, p=0.001). CONCLUSIONS In patients undergoing elective percutaneous coronary intervention, DAPR to aspirin and clopidogrel is present in one in five patients and is associated with a high risk for atherothrombotic events. DAPR measured by the point-of-care VerifyNow system has a higher predictability for atherothrombotic events than LTA. CLINICAL TRIAL REGISTRATION INFORMATION www.clinicaltrials.gov: NCT00352014.
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Affiliation(s)
- Nicoline J Breet
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
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Bouman HJ, Schömig E, van Werkum JW, Velder J, Hackeng CM, Hirschhäuser C, Waldmann C, Schmalz HG, ten Berg JM, Taubert D. Paraoxonase-1 is a major determinant of clopidogrel efficacy. Nat Med 2010; 17:110-6. [PMID: 21170047 DOI: 10.1038/nm.2281] [Citation(s) in RCA: 361] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 11/22/2010] [Indexed: 12/14/2022]
Abstract
Clinical efficacy of the antiplatelet drug clopidogrel is hampered by its variable biotransformation into the active metabolite. The variability in the clinical response to clopidogrel treatment has been attributed to genetic factors, but the specific genes and mechanisms underlying clopidogrel bioactivation remain unclear. Using in vitro metabolomic profiling techniques, we identified paraoxonase-1 (PON1) as the crucial enzyme for clopidogrel bioactivation, with its common Q192R polymorphism determining the rate of active metabolite formation. We tested the clinical relevance of the PON1 Q192R genotype in a population of individuals with coronary artery disease who underwent stent implantation and received clopidogrel therapy. PON1 QQ192 homozygous individuals showed a considerably higher risk than RR192 homozygous individuals of stent thrombosis, lower PON1 plasma activity, lower plasma concentrations of active metabolite and lower platelet inhibition. Thus, we identified PON1 as a key factor for the bioactivation and clinical activity of clopidogrel. These findings have therapeutic implications and may be exploited to prospectively assess the clinical efficacy of clopidogrel.
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Affiliation(s)
- Heleen J Bouman
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
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28
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Harmsze AM, Van Werkum JW, Moral F, Ten Berg JM, Hackeng CM, Klungel OH, De Boer A, Deneer VHM. Sulfonylureas and on-clopidogrel platelet reactivity in type 2 diabetes mellitus patients. Platelets 2010; 22:98-102. [DOI: 10.3109/09537104.2010.530359] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Breet NJ, VAN Werkum JW, Bouman HJ, Kelder JC, Ten Berg JM, Hackeng CM. Do not adjust the platelet count in light transmittance aggregometry when predicting thrombotic events after percutaneous coronary intervention. J Thromb Haemost 2010; 8:2326-8. [PMID: 20695984 DOI: 10.1111/j.1538-7836.2010.04003.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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30
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Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Ten Berg JM, Hackeng CM. High on-aspirin platelet reactivity as measured with aggregation-based, cyclooxygenase-1 inhibition sensitive platelet function tests is associated with the occurrence of atherothrombotic events. J Thromb Haemost 2010; 8:2140-8. [PMID: 20723029 DOI: 10.1111/j.1538-7836.2010.04017.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND High on-aspirin platelet reactivity (HAPR) is associated with atherothrombotic events following percutaneous coronary intervention (PCI). The aim of the present study was to identify the platelet function test sensitive for platelet cyclooxygenase-1 inhibition that best predicts atherothrombotic events. METHODS AND RESULTS Nine hundred and fifty-one consecutive patients on dual antiplatelet therapy undergoing elective PCI were enrolled. On-aspirin platelet reactivity was measured in parallel by arachidonic acid (AA)-induced light transmittance aggregometry (AA-induced LTA), the VerifyNow® Aspirin Assay (VerifyNow® Aspirin Assay), the arachidonic acid prestimulated IMPACT-R (IMPACT-R AA) and the PFA-100 collagen/epinephrine cartridge (PFA COL/EPI). Cut-offs for HAPR were established by receiver-operator characteristic curve analysis. At 1-year follow-up, the composite of all-cause death, non-fatal acute myocardial infarction, stent thrombosis and ischemic stroke occurred more frequently in patients with HAPR when assessed by LTA [10.1% vs. 6.0%, P=0.020 (n=925)] and VerifyNow(®) [13.3% vs. 5.9%, P=0.015 (n=422)]. The VerifyNow(®) ASA assay (AUC=0.78) and, to a lesser extent, AA-induced LTA (AUC=0.73) added significantly to a model consisting of clinical and procedural risk factors in predicting atherothrombotic events. In contrast, the IMPACT-R (n=791) and the PFA Collagen/Epinephrine (n=719) were unable to discriminate between patients with and without primary endpoint at 1-year follow-up. None of the platelet function tests was able to identify patients at risk for bleeding. CONCLUSIONS AA-induced LTA and the VerifyNow(®) ASA test were able to identify aspirin-treated patients undergoing PCI with stenting at risk for atherothrombotic events. The VerifyNow(®) Aspirin Assay had the highest predictive accuracy. None of the tests was able to identify patients at higher risk of bleeding.
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Affiliation(s)
- N J Breet
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
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Harmsze AM, van Werkum JW, Ten Berg JM, Zwart B, Bouman HJ, Breet NJ, van 't Hof AWJ, Ruven HJT, Hackeng CM, Klungel OH, de Boer A, Deneer VHM. CYP2C19*2 and CYP2C9*3 alleles are associated with stent thrombosis: a case-control study. Eur Heart J 2010; 31:3046-53. [PMID: 20833683 DOI: 10.1093/eurheartj/ehq321] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AIMS despite treatment with clopidogrel on top of aspirin, stent thrombosis (ST) still occurs being the most serious complication after percutaneous coronary interventions (PCIs). In this study, we aimed to determine the effect of variations in genes involved in the absorption (ABCB1 C1236T, G2677T/A, C3435T), metabolism (CYP2C19*2 and *3, CYP2C9*2 and *3, CYP3A4*1B and CYP3A5*3), and pharmacodynamics (P2Y1 A1622G) of clopidogrel on the occurrence of ST. METHODS AND RESULTS the selected genetic variants were assessed in 176 subjects who developed ST while on dual antiplatelet therapy with aspirin and clopidogrel and in 420 control subjects who did not develop adverse cardiovascular events, including ST, within 1 year after stenting. The timing of the definite ST was acute in 66, subacute in 87, and late in 23 cases. The presence of the CYP2C19*2 and CYP2C9*3 variant alleles was significantly associated with ST (OR(adj): 1.7, 95% CI: 1.0-2.6, P = 0.018 and OR(adj): 2.4, 95% CI: 1.0-5.5, P = 0.043, respectively). The influence of CYP2C19*2 (OR(adj): 2.5, 95% CI: 1.1-5.5, P = 0.026) and CYP2C9*3 (OR(adj): 3.3, 95% CI: 1.1-9.9, P = 0.031) was most strongly associated with subacute ST. No significant associations of the other genetic variations and the occurrence of ST were found. CONCLUSION carriage of the loss-of-function alleles CYP2C19*2 and CYP2C9*3 increases the risk on ST after PCI.
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Affiliation(s)
- Ankie M Harmsze
- Department of Clinical Pharmacy, St Antonius Hospital, PO Box 2500, Nieuwegein 3430 EM, The Netherlands.
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Elsenberg EHAM, van Werkum JW, van de Wal RMA, Zomer AC, Bouman HJ, Verheugt FWA, Berg JMT, Hackeng CM. The influence of clinical characteristics, laboratory and inflammatory markers on 'high on-treatment platelet reactivity' as measured with different platelet function tests. Thromb Haemost 2010; 102:719-27. [PMID: 19806258 DOI: 10.1160/th09-05-0285] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High on-clopidogrel platelet reactivity (HCPR) and high on-aspirin platelet reactivity (HAPR) are independently associated with an increased risk of atherothrombotic events. However, despite this positive correlation, the definitions of both HCPR and HAPR vary largely throughout studies and between different platelet function assays. The aim of the present study was to explore clinical and laboratory parameters that are associated with HCPR and HAPR as measured with different platelet function tests. 530 clopidogrel and aspirin pre-treated patients undergoing elective PCI (percutaneous coronary intervention) were enrolled. Platelet function measurements were performed with: optical aggregometry, the VerifyNow device and PFA-100 cartridges (including the novel INNOVANCE P2Y assay). HCPR as measured with Adenosin-Di-Phospate-induced (ADP) aggregation based tests was associated with clinical factors such as older age, female gender and Diabetes mellitus (DM). The VerifyNow P2Y12 assay was significantly influenced by haemoglobin and haematocrit levels. HAPR as measured with aggregation based tests was significantly influenced by the presence of malignancy, BMI (Body-Mass Index), older age and increased levels of hsCRP (high sensitivity c-reactive proteine). The PFA-100 COL/EPI (collagen-epinephrine) and COL/ADP (collagen-ADP) cartridges were significantly influenced by monocyte count, hs-CRP, MPV (mean platelet volume), vWF-antigen (von Willebrand factor) and vWF-activity. HCPR as measured with the novel INNOVANCE P2Y cartridge was associated with clinical determinants such as BMI, female gender, impaired LVEF (left ventricular ejection fraction), renal failure and dosing of clopidogrel. Laboratory markers that were associated with HCPR as measured with INNOVANCE P2Y were platelet count, white blood cells (WBC), hsCRP and fibrinogen. Both HCPR and HAPR are highly dependent on the type of platelet function assay. Each platelet function assay, in turn, is significantly influenced by distinct clinical and laboratory variables.
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Affiliation(s)
- Ellen H A M Elsenberg
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, The Netherlands
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33
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Abstract
IMPORTANCE OF THE FIELD The individual response to clopidogrel therapy is unpredictable, resulting in high on-treatment platelet reactivity in a substantial number of patients. Moreover, consistent findings across multiple investigations point out that a strong relationship exists between high on-treatment platelet reactivity and the occurrence of atherothrombotic events. AREAS COVERED IN THIS REVIEW This paper describes the current available methods of platelet function evaluation, including their advantages and drawbacks, reviews the evidence for the relation between high on-treatment platelet reactivity and clinical outcome, and discusses data concerning the clinical implications of platelet function testing in patients treated with thienopyridine therapy. WHAT THE READER WILL GAIN The reader will be introduced to platelet function testing and its clinical applicability. The reader will gain a better understanding of the techniques used and will learn how to interpret the numerous data on platelet function testing and clinical outcome. TAKE HOME MESSAGE Although a growing body of evidence demonstrates the promising potential of platelet function tests in predicting atherothrombotic events post stenting, platelet function testing should not yet be used routinely, as adequate treatment of high on-treatment platelet reactivity is unknown.
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Affiliation(s)
- Nicoline J Breet
- St Antonius Hospital, Department of Cardiology, PO Box 2500, 3435 CM Nieuwegein, The Netherlands +31 306099111 ; +31 306034420 ;
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Bouman HJ, Parlak E, van Werkum JW, Breet NJ, ten Cate H, Hackeng CM, ten Berg JM, Taubert D. Which platelet function test is suitable to monitor clopidogrel responsiveness? A pharmacokinetic analysis on the active metabolite of clopidogrel. J Thromb Haemost 2010; 8:482-8. [PMID: 20040042 DOI: 10.1111/j.1538-7836.2009.03733.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple platelet function tests claim to be P2Y12-pathway specific and capable of capturing the biological activity of clopidogrel. OBJECTIVES The aim of the present study was to determine which platelet function test provides the best reflection of the in vivo plasma levels of the active metabolite of clopidogrel (AMC). PATIENTS/METHODS Clopidogrel-naive patients scheduled for elective percutaneous coronary intervention (PCI) received a 600 mg loading dose of clopidogrel and 100 mg of aspirin. For pharmacokinetic analysis, blood was drawn at 0, 20, 40, 60, 90, 120, 180, 240 and 360 min after clopidogrel loading and peak plasma concentrations (C(max)) of the AMC were quantified with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Platelet function testing was performed at baseline and 360 min after the clopidogrel loading. RESULTS The VASP-assay, the VerifyNow P2Y12-assay and 20 micromol L(-1) adenosine diphosphate (ADP)-induced light transmittance aggregometry (LTA) showed strong correlations with C(max) of the AMC (VASP: R(2) = 0.56, P < 0.001; VerifyNow platelet reactivity units (PRU): R(2) = 0.48, P < 0.001; VerifyNow %inhibition: R(2) = 0.59, P < 0.001; 20 micromol L(-1) ADP-induced LTA: R(2) = 0.47, P < 0.001). Agreement with C(max) of the AMC was less evident for 5 micromol L(-1) ADP-induced LTA or whole blood aggregometry (WBA), whereas the IMPACT-R ADP test did not show any correlation with plasma levels of the AMC. CONCLUSION The flow cytometric VASP-assay, the VerifyNow P2Y12 assay and, although to a lesser extent, 20 micromol L(-1) ADP-induced LTA correlate best with the maximal plasma level of the AMC, suggesting these may be the preferred platelet function tests for monitoring the responsiveness to clopidogrel.
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Affiliation(s)
- H J Bouman
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
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35
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Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Ruven HJT, Bal ET, Deneer VH, Harmsze AM, van der Heyden JAS, Rensing BJWM, Suttorp MJ, Hackeng CM, ten Berg JM. Comparison of platelet function tests in predicting clinical outcome in patients undergoing coronary stent implantation. JAMA 2010; 303:754-62. [PMID: 20179285 DOI: 10.1001/jama.2010.181] [Citation(s) in RCA: 635] [Impact Index Per Article: 45.4] [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] [Indexed: 12/13/2022]
Abstract
Context High on-treatment platelet reactivity is associated with atherothrombotic events following coronary stent implantation. Objective To evaluate the capability of multiple platelet function tests to predict clinical outcome. Design, Setting, and Patients Prospective, observational, single-center cohort study of 1069 consecutive patients taking clopidogrel undergoing elective coronary stent implantation between December 2005 and December 2007. On-treatment platelet reactivity was measured in parallel by light transmittance aggregometry, Verify Now P2Y12 and Platelet works assays, and the IMPACT-R and the platelet function analysis system (PFA-100) (with the Dade PFA collagen/adenosine diphosphate (ADP) cartridge and Innovance PFA P2Y). Cutoff values for high on-treatment platelet reactivity were established by receiver operating characteristic curve (ROC) analysis. Main Outcome Measurement The primary end point was defined as a composite of all-cause death, nonfatal acute myocardial infarction, stent thrombosis, and ischemic stroke. The primary safety end point included TIMI (Thrombolysis In Myocardial Infarction) criteria major and minor bleeding. Results Kaplan-Meier analysis demonstrated that at 1-year follow-up, the primary end point occurred more frequently in patients with high on-treatment platelet reactivity when assessed by light transmittance aggregometry (52 [11.7%; 95% confidence interval {CI}, 8.9%-15.0%] vs 36 [6.0%;95%CI, 4.2%-8.2%] P.001; n=1049),Verify Now (54 [13.3%; 95% CI, 10.2%-17.0%] vs 37 [5.7%; 95% CI, 4.1%-7.8%]P.001; n=1052), Platelet works (33 [12.6%; 95% CI, 8.8%-17.2%] vs 21 [6.1%;95% CI, 3.8%-9.2%] P=.005; n=606), and Innovance PFA P2Y (18 [12.2%; 95%CI; 7.4%-18.6%] vs 28 [6.3%; 95% CI, 4.3%-8.9%] P=.02; n=588). ROC-curve analysis demonstrated that light transmittance aggregometry (area under the curve[AUC], 0.63; 95% CI, 0.58-0.68), Verify Now (AUC, 0.62; 95% CI, 0.57-0.67), and Platelet works (AUC, 0.61; 95% CI, 0.53-0.69) had modest ability to discriminate between patients with and without primary end point at 1-year follow-up. The IMPACT-R(n=905) and the Siemens PFA Collagen/ADP (n=812) were unable to discriminate between patients with and without the primary end point at 1-year follow-up (all AUCs included 0.50 in the CI). None of the tests identified patients at risk for bleeding. Conclusions Of the platelet function tests assessed, light transmittance aggregometry,Verify Now, Platelet works, and Innovance PFA P2Y were significantly associated with the primary end point. However, the predictive accuracy of these 4 tests was only modest. None of the tests provided accurate prognostic information to identify patients at higher risk of bleeding following stent implantation. Trial Registration clinical trials.gov Identifier: NCT00352014 [corrected].
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Affiliation(s)
- Nicoline J Breet
- Department of Cardiology, St Antonius Hospital, PO Box 2500, 3435 CM Nieuwegein, The Netherlands
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Bouman HJ, van Werkum JW, Rudez G, Leebeek FWG, Kruit A, Hackeng CM, Ten Berg JM, de Maat MPM, Ruven HJT. The influence of variation in the P2Y12 receptor gene on in vitro platelet inhibition with the direct P2Y12 antagonist cangrelor. Thromb Haemost 2009; 103:379-86. [PMID: 20126830 DOI: 10.1160/th09-06-0367] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Accepted: 10/10/2009] [Indexed: 11/05/2022]
Abstract
Novel P2Y12 inhibitors are in development to overcome the occurrence of atherothrombotic events associated with poor responsiveness to the widely used P2Y12 inhibitor clopidogrel. Cangrelor is an intravenously administered P2Y12 inhibitor that does not need metabolic conversion to an active metabolite for its antiplatelet action, and as a consequence exhibits a more potent and consistent antiplatelet profile as compared to clopidogrel. It was the objective of this study to determine the contribution of variation in the P2Y12 receptor gene to platelet aggregation after in vitro partial P2Y12 receptor blockade with the direct antagonist cangrelor. Optical aggregometry was performed at baseline and after in vitro addition of 0.05 and 0.25 microM cangrelor to the platelet-rich plasma of 254 healthy subjects. Five haplotype-tagging (ht)-SNPs covering the entire P2Y12 receptor gene were genotyped (rs6798347C>t, rs6787801T>c, rs9859552C>a, rs6801273A>g and rs2046934T>c [T744C]) and haplotypes were inferred. The minor c allele of SNP rs6787801 was associated with a 5% lower 20 microM ADP-induced peak platelet aggregation (0.05 microM cangrelor, p<0.05). Aa homozygotes for SNP rs9859552 showed 20% and 17% less inhibition of platelet aggregation with cangrelor when compared to CC homozygotes (0.05 and 0.25 microM cangrelor respectively; p<0.05). Results of the haplotype analyses were consistent with those of the single SNPs. Polymorphisms of the P2Y12 receptor gene contribute significantly to the interindividual variability in platelet inhibition after partial in vitro blockade with the P2Y12 antagonist cangrelor.
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Affiliation(s)
- H J Bouman
- Department of Cardiology, St Antonius Hospital, P.O. Box 2500, 3435 CM Nieuwegein, The Netherlands.
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Pittens CACM, Bouman HJ, van Werkum JW, ten Berg JM, Hackeng CM. Comparison between hirudin and citrate in monitoring the inhibitory effects of P2Y12 receptor antagonists with different platelet function tests. J Thromb Haemost 2009; 7:1929-32. [PMID: 19691484 DOI: 10.1111/j.1538-7836.2009.03585.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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38
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Rudež G, Bouman HJ, van Werkum JW, Leebeek FW, Kruit A, Ruven HJ, ten Berg JM, de Maat MP, Hackeng CM. Common Variation in the Platelet Receptor
P2RY12
Gene Is Associated With Residual On-Clopidogrel Platelet Reactivity in Patients Undergoing Elective Percutaneous Coronary Interventions. ACTA ACUST UNITED AC 2009; 2:515-21. [DOI: 10.1161/circgenetics.109.861799] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The clinical efficacy of clopidogrel is hampered by a large interindividual variability in platelet inhibition. Polymorphisms in the
P2RY12
receptor gene have been suggested to contribute to this variability, but previous studies included a relatively small number of patients and incompletely covered the common variation in the
P2RY12
gene. The aim of this study was to comprehensively investigate the possible association between common variation in the entire
P2RY12
locus and the magnitude of residual on-clopidogrel platelet reactivity measured by 2 commonly used platelet function assays in a large cohort of patients.
Methods and Results—
A total of 1031 consecutive patients with coronary artery disease who were scheduled for elective percutaneous coronary interventions were enrolled. Platelet function was assessed by means of ADP-induced light-transmittance aggregometry and the VerifyNow P2Y12 assay. Six haplotype-tagging single nucleotide polymorphisms were carefully selected to comprehensively cover the total common variation in the
P2RY12
gene and its flanking regulatory regions. Six common haplotypes were inferred from these haplotype-tagging single nucleotide polymorphisms (denoted A to F). Haplotype F was associated with significantly lower residual on-clopidogrel platelet reactivity compared with the reference haplotype A. The size of this effect per haplotype allele was approximately 5% aggregation in the ADP-induced light-transmittance aggregometry (
P
<0.05) and 11 P2Y12 reaction units in the VerifyNow P2Y12 assay (
P
<0.05).
Conclusions—
Common variation in the
P2RY12
gene is a significant determinant of the interindividual variability in residual on-clopidogrel platelet reactivity in patients with coronary artery disease.
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Affiliation(s)
- Goran Rudež
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Heleen J. Bouman
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jochem W. van Werkum
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank W.G. Leebeek
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Adrian Kruit
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Hendrik J.T. Ruven
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jurriën M. ten Berg
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Moniek P.M. de Maat
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Christian M. Hackeng
- From the Department of Hematology (G.R., F.W.G.L., M.P.M.M.), Erasmus University Medical Center, Rotterdam, The Netherlands; and Departments of Cardiology (H.J.B., J.W.W., J.M.B.) and Clinical Chemistry (A.K., H.J.T.R., C.M.H.), St. Antonius Hospital, Nieuwegein, The Netherlands
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van der Stelt CAK, van Werkum JW, Seesing TH, Ten Berg JM, Hackeng CM. To adjust or not to adjust the platelet count in light transmission aggregometry in patients receiving dual aspirin/clopidogrel treatment. Platelets 2009; 18:550-3. [DOI: 10.1080/09537100701326721] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bouman HJ, van Werkum JW, Hackeng CM, Verheugt FWA, Ten Berg JM. The importance of anticoagulant agents in measuring platelet aggregation in patients treated with clopidogrel and aspirin. J Thromb Haemost 2008; 6:1040-2. [PMID: 18394013 DOI: 10.1111/j.1538-7836.2008.02971.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Werkum JW, Hackeng CM, Smit JJJ, van’t Hof AWJ, Verheugt FWA, ten Berg JM. Monitoring antiplatelet therapy with point-of-care platelet function assays: a review of the evidence. Future Cardiol 2008; 4:33-55. [DOI: 10.2217/14796678.4.1.33] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Multiple studies have demonstrated that subgroups of patients receiving combination therapy with aspirin and clopidogrel fail to produce the anticipated antiplatelet effect, and various terms such as ‘aspirin resistance’, ‘clopidogrel resistance’, ‘heightened post-treatment platelet reactivity’ and ‘residual platelet reactivity’ have been introduced in the medical literature. Light transmittance aggregometry is generally considered to be the gold standard for determining platelet function, but its relevance to in vivo platelet function is questionable and the logistical demands of the method make it impossible to use in daily practice. The introduction of several point-of-care platelet function assays may be the key to the widespread clinical use of platelet function testing and may identify patients who are at risk for the occurrence of adverse cardiac events. In the present paper, we discuss the current commercially available methods of assaying platelet function, including their advantages and limitations and whether they have been shown to correlate with clinical outcomes.
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Affiliation(s)
- Jochem W van Werkum
- St Antonius Center for Platelet Function Research, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Christian M Hackeng
- St Antonius Center for Platelet Function Research, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Jaap-Jan J Smit
- Isala Klinieken, Department of Cardiology, Zwolle Groot Wezenland 20, 8011 JW Zwolle, The Netherlands
| | - Arnoud WJ van’t Hof
- Isala Klinieken, Department of Cardiology, Zwolle Groot Wezenland 20, 8011 JW Zwolle, The Netherlands
| | - Freek WA Verheugt
- University Medical Center St Radboud, Department of Cardiology, PO Box 9101, Nijmegen, The Netherlands
| | - Jurriën M ten Berg
- St Antonius Center for Platelet Function Research, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
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van Werkum JW, Kleibeuker M, Mieremet N, ten Berg JM, Hackeng CM. Evaluation of the platelet response to clopidogrel with light transmittance aggregometry: peak aggregation or late aggregation? J Thromb Haemost 2007; 5:884-6. [PMID: 17403207 DOI: 10.1111/j.1538-7836.2007.02370.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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van Werkum JW, van der Stelt CAK, Seesing TH, ten Berg JM, Hackeng CM. The flow cytometric VASP assay can be used to determine the effectiveness of clopidogrel in patients treated with abciximab. J Thromb Haemost 2007; 5:881-3. [PMID: 17263784 DOI: 10.1111/j.1538-7836.2007.02421.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van Werkum JW, van der Stelt CAK, Seesing TH, Hackeng CM, ten Berg JM. A head-to-head comparison between the VerifyNow P2Y12 assay and light transmittance aggregometry for monitoring the individual platelet response to clopidogrel in patients undergoing elective percutaneous coronary intervention. J Thromb Haemost 2006; 4:2516-8. [PMID: 16938130 DOI: 10.1111/j.1538-7836.2006.02187.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The antiplatelet agent clopidogrel in combination with aspirin has been shown to reduce thrombotic events in patients with acute coronary syndromes and/or who are undergoing percutaneous coronary intervention. However, a large interindividual response variability to clopidogrel has been described. The reported rates of inadequate clopidogrel response vary considerably depending on the definition and methodologies used to measure the inhibition of platelet function. Recently, several (small) studies have demonstrated the clinical relevance of an inadequate response to clopidogrel. Moreover, several factors have been associated with a high interindividual variability in response to clopidogrel. These are: dosing, impaired intestinal absorption, cytochrome P450 3A4 and 3A5 activity, drug–drug interactions, polymorphisms of the receptors involved in the process of arterial thrombosis and hemostasis, and the method of measurement of platelet function. Future research for the evaluation of clopidogrel resistance should be based on the assessment of selective P2Y12 receptor inhibition (e.g., the vasodilator-stimulated phosphoprotein-assay or the measurement of stabilization of platelet aggregates) with quick and simple tests. Only then can we reveal the true prevalence and impact of clopidogrel resistance.
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Affiliation(s)
- JW van Werkum
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - AACM Heestermans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - VHM Deneer
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - CM Hackeng
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - JM ten Berg
- Department of Cardiology, St. Antonius Hospital, PO Box 2500 3435 CM Nieuwegein, The Netherlands
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Michielsen ECHJ, Diris JHC, Hackeng CM, Wodzig WKWH, Van Dieijen-Visser MP. Highly Sensitive Immunoprecipitation Method for Extracting and Concentrating Low-Abundance Proteins from Human Serum. Clin Chem 2005; 51:222-4. [PMID: 15613717 DOI: 10.1373/clinchem.2004.036251] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Etienne C H J Michielsen
- Department of Clinical Chemistry, University Hospital Maastricht, Maastricht 6202 AZ, The Netherlands
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Abstract
Background—
Patients with severe renal dysfunction often have unexplained elevated serum concentrations of cardiac troponin T (cTnT). We investigated whether in vivo fragmentation of cTnT could explain these increases.
Methods and Results—
cTnT, creatine kinase isoenzyme MB, and myoglobin serum concentrations were measured in all 63 dialysis patients of our in-hospital dialysis department. A highly sensitive immunoprecipitation assay, followed by electrophoresis and Western blotting, was used to extract and concentrate cTnT and its possible fragments from serum of these 63 hemodialysis patients. Although creatine kinase isoenzyme MB values excluded recent ischemic myocardial events in 55 of the 63 cases, cTnT fragments ranging in size from 8 to 25 kDa were present in the serum samples of all dialysis patients.
Conclusions—
cTnT is fragmented into molecules small enough to be cleared by the kidneys of healthy subjects. Impaired renal function causes accumulation of these cTnT fragments and is very likely the cause of the unexplained elevations of serum cTnT found in patients with severe renal failure.
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Affiliation(s)
- Jart H C Diris
- Department of Clinical Chemistry, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Hackeng CM, Beerenhout CM, Hermans M, Van der Kuy PHM, Van der Dussen H, Van Dieijen-Visser MP, Hamulyák K, Van der Sande FM, Leunissen KM, Kooman JP. The relationship between reticulocyte hemoglobin content with C-reactive protein and conventional iron parameters in dialysis patients. J Nephrol 2004; 17:107-11. [PMID: 15151266] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Adequate iron stores are a prerequisite for successful erythropoietin (EPO) therapy in hemodialysis (HD) patients. Nevertheless, iron status estimation in HD patients remains problematic, as most parameters are influenced by inflammation. The reticulocyte hemoglobin content (CHr) has recently been proposed as a useful tool in iron status assessment. However, the effect of inflammation on CHr remains unstudied. This study aimed to assess the relationship between CHr with other parameters of iron status as well as with C-reactive protein (CRP). This relationship was studied in all the patients (n=61) at our dialysis unit. CHr was significantly and positively related to transferrin saturation (TS) (rho=0.26; p<0.05) and inversely to the percentage of hypochromic red blood cells (%Hypo) (rho=-0.63; p<0.0001), but not to serum ferritin. CHr was strongly and inversely related to log CRP (rho=-0.50; p<0.0001). Despite the use of maintenance intravenous (i.v.) iron doses and relatively high serum ferritin levels, a large percentage of patients were in a state of functional iron deficiency (%Hypo > or = 6 in 41% of patients and CHr < or = 29 pg in 13% of patients). This percentage was far lower in patients with CRP levels below the detection limit (2 mg/L) (26% and 0%, respectively). In conclusion, CHr is related to both TS and %Hypo, but not to serum ferritin, and is strongly influenced by the presence of inflammation (as determined by CRP). In patients with elevated CRP levels, it is very difficult to reach target iron status levels without exceeding the upper limits for serum ferritin.
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Affiliation(s)
- Christian M Hackeng
- Department of Clinical Chemistry, University Hospital Maastricht, The Netherlands
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Abstract
Events leading to hyperactivity of human blood platelets are accompanied by an enhanced risk of atherosclerosis and arterial thrombosis. Lipoprotein disorders affect platelet functions, and hypersensitive platelets are observed in various stages of hyperlipidemia. Low-density lipoprotein (LDL), a circulating complex of lipids and proteins that is increased in hypercholesterolemia, enhances platelet function and increases sensitivity of platelets to several naturally occurring agonists. LDL sensitizes platelets via binding of apoB-100 to a receptor on the platelet membrane and via transfer of lipids to the platelet membrane. The receptor that mediates binding of LDL to the platelet and initiates subsequent intracellular signaling cascades has not yet been identified. Modification of native LDL generates a platelet-activating particle, and this interaction might contribute to the development of the atherosclerotic plaque. Lysophosphatidic acid is formed upon mild oxidation of LDL and is responsible for subsequent platelet activation induced by the modified LDL particle. Thus, LDL changes the functions of platelets via a broad spectrum of interactions.
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Affiliation(s)
- I A M Relou
- University Medical Center Utrecht, Laboratory for Thrombosis and Haemostasis, G.03.647, Department of Hematology, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Hackeng CM, de Bruijn LAM, Douw CM, van Dieijen-Visser MP. Presence of Birefringent, Maltese-Cross-appearing Spherules in Synovial Fluid in a Case of Acute Monoarthritis. Clin Chem 2000. [DOI: 10.1093/clinchem/46.11.1861] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christian M Hackeng
- Department of Clinical Chemistry, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Leonne A M de Bruijn
- Department of Clinical Chemistry, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Connie M Douw
- Department of Orthopedics, Bosch Medical Centre, PO Box 90.153, 5200 ME ’s Hertogenbosch, The Netherlands
| | - Marja P van Dieijen-Visser
- Department of Clinical Chemistry, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands
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