Monotherapy with P2Y12-inhibitors after dual antiplatelet therapy: Filling gaps in evidence

BACKGROUND

Whether P2Y12 inhibitor monotherapy (P2Y12-I) is superior to aspirin following DAPT discontinuation post-PCI remains to be established.

METHODS

We updated our prior network meta-analysis where P2Y12-I and aspirin had been compared with DAPT or directly with each other. The focus is specifically on the available direct evidence, now consisting of the three head-to-head comparisons of P2Y12-I and aspirin in event-free PCI patients after DAPT. We include a Trial Sequential Analysis of the direct evidence based on meta-analytical literature.

RESULTS

The main finding reveals a 39% significantly lower risk of myocardial infarction with P2Y12-I (RR 0.61, 95% CI 0.47-0.78, p = 0.0001, I2 = 0%) with no difference in bleeding. Trial Sequential Analysis demonstrates clinically meaningful evidence for a reduction in the incidence of myocardial infarction with P2Y12-I that is also supported by statistical significance.

CONCLUSIONS

Accruing data highlight that P2Y12-I following DAPT discontinuation after PCI is associated with lower risk for MI and a similar risk for bleeding as compared with ASA. In light of potential limitations to the widespread adoption of life-long P2Y12-I treatment, clinicians should consider identifying selected patients who are expected to derive the highest benefit.

Dual Antiplatelet Therapy with Parenteral P2Y12 Inhibitors: Rationale, Evidence, and Future Directions

Dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and an inhibitor of the platelet P2Y₁₂ receptor for ADP, remains among the most investigated treatments in cardiovascular medicine. While a substantial amount of research initially stemmed from the observations of late and very late stent thrombosis events in the first-generation drug-eluting stent (DES) era, DAPT has been recently transitioning from a purely stent-related to a more systemic secondary prevention strategy. Oral and parenteral platelet P2Y₁₂ inhibitors are currently available for clinical use. The latter have been shown to be extremely suitable in drug-naïve patients with acute coronary syndrome (ACS), mainly because oral P2Y₁₂ inhibitors are associated with delayed efficacy in patients with STEMI and because pre-treatment with P2Y₁₂ inhibitors is discouraged in NSTE-ACS, and in patients with recent DES implantation and in need of urgent cardiac and non-cardiac surgery. More definitive evidence is needed, however, about optimal switching strategies between parenteral and oral P2Y₁₂ inhibitors and about newer potent subcutaneous agents that are being developed for the pre-hospital setting.

631 THE IMPACT OF BMI ON MYOCARDIAL WORK AND LEFT ATRIAL STRAIN IN YOUNG OVERWEIGHT PATIENTS WITH PRESERVED LEFT VENTRICULAR EJECTION FRACTION

Introduction

Overweight and obesity are a health problem of growing significance all over the world with increasing prevalence in both developed and developing countries. Numerous studies have demonstrated a relationship between obesity and cardiovascular diseases, underscoring the need to early treat this pathological condition. Overweight and obesity cause structural and functional changes on left ventricular (LV) and left atrial (LA) performance, which lead to heart failure. In this context we aimed to evaluate the impact of BMI on myocardial work parameters and left atrial strain to early detect LV and LA performance changes in overweight patients.

Methods

80 young individuals were prospectively enrolled, distinguishing between overweight patients with BMI greater than or equal to 25 to 29.9 kg/m^2 (n= 36; 45±11 years) and normal weight patients with BMI greater than or equal to 18.5 to 24.9 kg/m^2 (n=44; 43±9 years). All patients underwent transthoracic echocardiogram to calculate global longitudinal strain (GLS), global work index (GWI), global work efficiency (GWE), global wasted work (GWW), global constructive work (GCW) and left atrial strain.

Results

Overweight patients have higher BSA (1,9±0,16 vs 1,6±0,17 mq; p<0,0001), Diastolic Blood pressure (81±12 vs 74±10 mmHg; p= 0,01) mean arterial pressure (98±15 vs 91±11 mmHg; p = 0,01), Heart Rate (71±13 vs 70±12 bpm; p= 0,02) and Global Longitudinal Strain (-19,3% ±1,7 vs -20,3% ±1,8; p = 0,02). With respect to myocardial work parameters, in overweight patients GWE (93% vs 95%; p=0,01) is significantly reduced, whereas GWW (132 vs 102 mmHg%; p=0,03) is significantly increased. Left atrial reservoir (LAres) (36% vs 40%; p=0,04) and conduit (-19% vs -24%; p=0,005) function are significantly reduced in overweight patients. BMI inversely correlates with GWE (r=-0,36; p=0,005) and LAres (r=-0,33; p=0,007), whereas it directly correlates with GWW (r=0,31; p = 0,006).

Conclusions

Overweight induces early LV and LA performance changes that can be precociously detected by myocardial work and left atrial strain, in order to better characterize individual cardiovascular risk profile.

The new HFA/ICOS risk assessment tool to identify patients with chronic myeloid leukaemia at high risk of cardiotoxicity

AIMS

Tyrosine kinase inhibitors (TKIs) used to treat chronic myeloid leukaemia (CML) can cause cardiovascular adverse events. So far, the Systematic Coronary Risk Evaluation (SCORE) charts of the European Society of Cardiology (ESC) have been used to identify cancer patients at increased cardiovascular risk. The primary aim of our study was to evaluate the usefulness of the new cardiovascular risk assessment model proposed by the Cardio-Oncology Study Group of the Heart Failure Association (HFA) of the ESC in collaboration with the International Cardio-Oncology Society (ICOS) to stratify the cardiovascular risk in CML patients, compared with SCORE risk charts. The secondary aim was to establish the incidence of adverse arterial events (AEs) in patients with CML treated with TKIs and the influence of preventive treatment with aspirin.

METHODS AND RESULTS

A retrospective single-centre observational study was carried out on 58 patients (32 men and 26 women; mean age ± SD: 59 ± 15 years) with CML treated with TKIs for a median period of 43 ± 31 months. Cardiological evaluation was performed and cardiovascular risk was estimated with SCORE risk charts and with the new risk assessment tool proposed by HFA/ICOS. AEs were recorded. According to SCORE charts and the new HFA/ICOS risk stratification tool, respectively, 46% (Group A1) and 60% (Group A2) of patients were at high-very high risk, and 54% (Group B1) and 40% (Group B2) at low-moderate risk. AEs were significantly more frequent in Group A1 than Group B1 (P value < 0.01) when considered overall; they were significantly more frequent in Group A2 than Group B2 either overall or considered individually. HFA/ICOS risk stratification tool was significantly more sensitive than SCORE (P < 0.01) in identifying patients at higher risk of cardiovascular toxicity. In addition, we did not find AEs in patients pretreated with aspirin.

CONCLUSIONS

The new HFA/ICOS risk stratification model allows a more tailored cardiovascular risk stratification in patients with CML and it is more sensitive than SCORE charts.

Usefulness of a new risk score in identifying patients with CML at increased risk of cardiovascular toxicities

Background

Anti-BCR-ABL tyrosine kinase inhibitors (TKIs) dramatically improved the prognosis of patients with Chronic Myeloid Leukemia (CML) however they have been associated with cardiovascular (CV) complications.

Purpose

The primary aim of our study was to compare the usefulness of two different tools to stratify the risk of developing cardiovascular adverse events in haematology patients treated with ponatinib or nilotinib.

Methods

A real-life retrospective observational study was carried out on 58 patients (32 M, 26 W; mean age ± SD: 59±15) affected by CML treated with TKIs for a median period of 43±31 months. Patients were divided in groups according to CV risk estimated with SCORE and the 2020 CV risk assessment proposed by the Cardio-Oncology Study Group of the ESC/ICOS. Cardiac evaluation and echocardiogram were performed in all patients. The recorded CV adverse events were: myocardial ischemia, peripheral vascular diseases, new-onset or progression of preexisting carotid atherosclerosis, arterial hypertension, arrhythmias.

Results

According to SCORE, 46% of patients were at high-very high risk (group A1) and 54% at low-moderate risk (group B1). Applying the ESC/ICOS risk stratification tools, 60% were at high-very high risk (group A2) and 40% at low-medium risk (group B2). 21 CV adverse events were observed. CV adverse events were significantly more frequent in group A1 than group B1 (p value = 0,0003) when considered overall, they were significantly more frequent in group A2 than group B2 either overall (p=0,0004) or considered individually (myocardial ischemia: p=0,01; peripheral arterial disease: p=0,03). See Table 1. Moreover, the ESC/ICOS risk stratification tools was significantly more sensitive than SCORE (p=0,0004) in identifying patients at higher risk of cardiovascular toxicity. See Table 2.

No patients treated with Ponatinib showed CV adverse events during follow up. It is worth of notice that all patients before starting treatment underwent cardio-oncological evaluation, risk factors correction and preventive treatment with aspirin. They also were treated with the lowest dose of TKI. None of the patients treated with nilotinib over 4 years and with multiple lines of therapy, experiencing adverse events, received aspirin in primary prevention.

Conclusions

Our study shows that the ESC/ICOS risk stratification tools is very sensitive and more performing than SCORE for risk stratification of cardiotoxicity in haematology patients treated with TKIs. It also suggests that baseline CV risk assessment, CV risk factors correction and preventive treatment with aspirin aid in reducing CV adverse events in patients treated with ponatinib.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Use of myocardial work for multiparametric detection of subclinical anthracycline cardiotoxicity in breast cancer patients

Funding Acknowledgements

Type of funding sources: None.

Background

The aim of our study was to assess subclinical cardiac effects of anthracyclines (ANTs) in women treated for breast cancer (BC).

Methods

We enrolled 46 female patients with BC undergoing adjuvant treatment with anthracycline-containing chemotherapy (CT) followed by taxane (paclitaxel/docetaxel).  Patients underwent physical examination, electrocardiogram (ECG) and standard transthoracic echocardiography (TTE) including evaluation of diastolic and systolic function, measured as left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (GLS) and myocardial work (MW) expressed as global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE). The parameters were measured at baseline (T0) and at 3 months (T1) and 6 months (T2) follow up.

Results

All patients completed the chemotherapy cycles. No significant cardiovascular adverse events were observed during treatment. Neither 2D left ventricular ejection fraction (LVEF) nor E/e’ ratio evaluation at TDI were significantly changed after treatment. Conversely, GLS was significantly reduced at T1 and T2 since baseline  (GLS - 19,99 % IQR -20,6 -19,3 % at T0 vs -17,88 % IQR -18,8 -16,9 % at T1, p&lt; 0,00 1 and -16,71 % IQR 17,6 -15,7 % at T2, p&lt; 0,001). Consensually, a significant reduction in myocardial work was also measured (GWI 2115 mmHg% IQR 1888 – 2342 mmHg%  at T0 vs 1714 mmHg% IQR 1557 – 1870 mmHg% at T1, p&lt; 0,0001 and 1694 mmHg% IQR 1482 – 1907 mmHg% at T2, p&lt; 0,0001).

Conclusion

Our study demonstrates that evaluation of myocardial work allows very early detection of subclinical cardiac damage induced by chemotherapy, consensually to the reduction of the GLS. A multiparametric assessment of the myocardial function, including myocardial work and GLS, could improve the accuracy of risk stratification of cardiotoxicity in patients undergoing ANTs treatment.

Multiparametric ultrasound evaluation with CEUS and shear wave elastography for carotid plaque risk stratification

PURPOSE

To assess the diagnostic effectiveness of Multiparametric ultrasound (MPUS), which includes color Doppler ultrasound (CDUS), CEUS and Shear wave elastography (SWE), for evaluating carotid plaque as compared with CT-angiography (CTA) and histology.

MATERIALS AND METHODS

Forty-three consecutive patients scheduled to undergo carotid endarterectomy underwent MPUS. Then, after periods ranging from 2 days to 2 weeks, all underwent CTA. Each plaque was classified by means of dedicated scores for CEUS and SWE as compared with CTA features. At surgery, each plaque was removed in a single fragment to facilitate histological analysis, which evaluated 4 features: extension of the lipid core, thickness of the fibrous cap, inflammatory infiltrate (CD68 + and CD3 + markers) and the presence of intraplaque microvessels. For the CEUS, SWE and CTA, the following values for identifying plaque vulnerability were evaluated: sensitivity, specificity, accuracy, negative predictive value (NPV), positive predictive value (PPV) and Area under the curve (AUC). Cohen's kappa was used to evaluate the concordance between measurements in the different imaging methods. A p < 0.05 was considered statistically significant.

RESULTS

At histology, 31 out of 43 plaques were identified as vulnerable because of the presence of at least one of the following criteria: fibrous cap < 200 μm, lipid core, intraplaque hemorrhage, inflammatory infiltrate or intraplaque neovascularization. CTA showed a sensitivity of 87.1%, a specificity of 100%, a PPV of 100%, an NPV of 75% and an AUC of 93.5%. SWE showed a sensitivity of 87.1%, a specificity of 66.7%, a PPV of 87.1%, an NPV of 66.7% and an AUC of 76.9%. CEUS showed a sensitivity of 87.1%, a specificity of 58.3%, a PPV of 84.4%, an NPV of 63.6% and an AUC of 72.7%.

CONCLUSIONS

Multiparametric ultrasound is an effective modality to obtain comprehensive information on carotid plaques. Further studies are needed to determine whether it can be considered a diagnostic standard.