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Tantry US, Bonello L, Aradi D, Price MJ, Jeong YH, Angiolillo DJ, Stone GW, Curzen N, Geisler T, Ten Berg J, Kirtane A, Siller-Matula J, Mahla E, Becker RC, Bhatt DL, Waksman R, Rao SV, Alexopoulos D, Marcucci R, Reny JL, Trenk D, Sibbing D, Gurbel PA. Consensus and update on the definition of on-treatment platelet reactivity to adenosine diphosphate associated with ischemia and bleeding. J Am Coll Cardiol 2013; 62:2261-73. [PMID: 24076493 DOI: 10.1016/j.jacc.2013.07.101] [Citation(s) in RCA: 710] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 07/29/2013] [Accepted: 07/31/2013] [Indexed: 12/28/2022]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker is a key strategy to reduce platelet reactivity and to prevent thrombotic events in patients treated with percutaneous coronary intervention. In an earlier consensus document, we proposed cutoff values for high on-treatment platelet reactivity to adenosine diphosphate (ADP) associated with post-percutaneous coronary intervention ischemic events for various platelet function tests (PFTs). Updated American and European practice guidelines have issued a Class IIb recommendation for PFT to facilitate the choice of P2Y12 receptor inhibitor in selected high-risk patients treated with percutaneous coronary intervention, although routine testing is not recommended (Class III). Accumulated data from large studies underscore the importance of high on-treatment platelet reactivity to ADP as a prognostic risk factor. Recent prospective randomized trials of PFT did not demonstrate clinical benefit, thus questioning whether treatment modification based on the results of current PFT platforms can actually influence outcomes. However, there are major limitations associated with these randomized trials. In addition, recent data suggest that low on-treatment platelet reactivity to ADP is associated with a higher risk of bleeding. Therefore, a therapeutic window concept has been proposed for P2Y12 inhibitor therapy. In this updated consensus document, we review the available evidence addressing the relation of platelet reactivity to thrombotic and bleeding events. In addition, we propose cutoff values for high and low on-treatment platelet reactivity to ADP that might be used in future investigations of personalized antiplatelet therapy.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Laurent Bonello
- Département de Cardiologie, Hôpital Universitaire Nord, Aix-Marseille University, Marseille, France
| | - Daniel Aradi
- Department of Cardiology, Heart Center Balatonfüred, Balatonfüred, Hungary
| | - Matthew J Price
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University, Jinju, South Korea
| | - Dominick J Angiolillo
- Cardiovascular Research Center, University of Florida College of Medicine, Jacksonville, Florida
| | - Gregg W Stone
- Cardiovascular Research and Education, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Nick Curzen
- Wessex Cardiothoracic Unit, University Hospital, Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Tobias Geisler
- Medizinische Klinik III, Kardiologie und Kreislauferkrankungen, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Jurrien Ten Berg
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Ajay Kirtane
- Cardiovascular Research and Education, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | | | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Richard C Becker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Deepak L Bhatt
- Veterans Affairs Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Waksman
- Interventional Cardiology, Medstar Washington Hospital Center, Washington, DC
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina
| | | | - Rossella Marcucci
- Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy
| | - Jean-Luc Reny
- Department of Internal Medicine, Rehabilitation, and Geriatrics, Geneva Platelet Group, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Dietmar Trenk
- Universitaets-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians Universität München, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland.
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Gurbel PA, Bliden KP, Logan DK, Kereiakes DJ, Lasseter KC, White A, Angiolillo DJ, Nolin TD, Maa JF, Bailey WL, Jakubowski JA, Ojeh CK, Jeong YH, Tantry US, Baker BA. The influence of smoking status on the pharmacokinetics and pharmacodynamics of clopidogrel and prasugrel: the PARADOX study. J Am Coll Cardiol 2013; 62:505-12. [PMID: 23602770 DOI: 10.1016/j.jacc.2013.03.037] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/21/2013] [Accepted: 03/20/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the effect of smoking on the pharmacokinetics and pharmacodynamics (PD) of clopidogrel and prasugrel therapy. BACKGROUND Major randomized trial data demonstrated that nonsmokers experience less or no benefit from clopidogrel treatment compared with smokers (i.e., the "smokers' paradox"). METHODS PARADOX was a prospective, randomized, double-blind, double-dummy, placebo-controlled, crossover study of objectively assessed nonsmokers (n = 56) and smokers (n = 54) with stable coronary artery disease receiving aspirin therapy. Patients were randomized to receive clopidogrel (75 mg daily) or prasugrel (10 mg daily) for 10 days and crossed over after a 14-day washout. PD was assessed by using VerifyNow P2Y12 and vasodilator-stimulated phosphoprotein phosphorylation assays. Clopidogrel and prasugrel metabolite levels, cytochrome P450 1A2 activity, CYP2C19 genotype, and safety parameters were determined. RESULTS During clopidogrel therapy, device-reported inhibition of platelet aggregation (IPA) trended lower in nonsmokers than smokers (least squares mean treatment difference ± SE: 7.7 ± 4.1%; p = 0.062). Device-reported IPA was significantly lower in clopidogrel-treated smokers than prasugrel-treated smokers (least squares mean treatment difference: 31.8 ± 3.4%; p < 0.0001). During clopidogrel therapy, calculated IPA was lower and P2Y12 reaction units and vasodilator-stimulated phosphoprotein phosphorylation and platelet reactivity index were higher in nonsmokers than in smokers (p = 0.043, p = 0.005, and p = 0.042, respectively). Greater antiplatelet effects were present after prasugrel treatment regardless of smoking status (p < 0.001 for all comparisons). CONCLUSIONS PARADOX demonstrated lower clopidogrel active metabolite exposure and PD effects of clopidogrel in nonsmokers relative to smokers. Prasugrel was associated with greater active metabolite exposure and PD effects than clopidogrel regardless of smoking status. The poorer antiplatelet response in clopidogrel-treated nonsmokers may provide an explanation for the smokers' paradox. (The Influence of Smoking Status on Prasugrel and Clopidogrel Treated Subjects Taking Aspirin and Having Stable Coronary Artery Disease; NCT01260584).
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Affiliation(s)
- Paul A Gurbel
- Sinai Center for Thrombosis Research, Baltimore, MD 21215, USA.
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