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Khalid AR, Ahmad F, Naeem MAB, Ahmed S, Umar M, Mehmood H, Kashif M, Ali S. Safety of Clopidogrel vs. Ticagrelor in Dual Antiplatelet Therapy Regimens for High-Bleeding Risk Acute Coronary Syndrome Patients: A Comprehensive Meta-analysis of Adverse Outcomes. High Blood Press Cardiovasc Prev 2024; 31:141-155. [PMID: 38557855 DOI: 10.1007/s40292-024-00635-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Patients of acute coronary syndrome (ACS) at a high-bleeding risk (HBR) often require dual antiplatelet therapy (DAPT) to reduce the risk of recurrent cardiovascular events. Clopidogrel and ticagrelor are the most commonly used antiplatelet agents in DAPT regimens. However, the safety profiles of these drugs in ACS patients at HBR remain a subject of ongoing debate. AIM To investigate any difference between the safety of clopidogrel and ticagrelor used as a part of DAPT regimen in ACS patients at HBR. METHODS A systematic search on PubMed, Cochrane Library, and Google Scholar was conducted to identify experimental and observational studies published up to the knowledge cutoff date in September 2023. Studies comparing the safety of clopidogrel and ticagrelor in ACS patients at HBR were included for analysis. The primary outcomes assessed were major bleeding events, stroke, and myocardial infarction (MI), while secondary outcomes included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and net adverse clinical and cerebral events (NACCE). RESULTS We included a total of 8 observational studies in our meta-analysis. The pooled analysis revealed a statistically significant increase in the risk of MI (pooled RR = 1.43; 95% CI 1.12-1.83; P = 0.005) in the patients using clopidogrel. There were no statistically significant differences in major bleeding events (pooled RR = 0.94; 95% CI 0.82-1.09; P = 0.44), stroke (pooled RR = 1.36; 95% CI 0.86-2.14; P = 0.18), all-cause mortality (pooled RR = 1.17; 95% CI 0.97-1.41; P = 0.10), MACCE (pooled RR = 1.07; 95% CI 0.76-1.50; P = 0.69) and NACCE (pooled RR = 0.95; 95% CI 0.66-1.37; P = 0.78) between the two groups. Subgroup analyses based on region were performed. CONCLUSION Both drugs are generally safe for treating ACS patients with HBR at baseline, although a higher risk of MI was observed with the use of clopidogrel. Nevertheless, drug choice should factor in regional variations, patient-specific characteristics, cost, accessibility, and potential drug interactions.
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Affiliation(s)
| | - Farooq Ahmad
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | - Smak Ahmed
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Muhammad Umar
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | | | - Shazib Ali
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
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Shiomi H, Hasegawa K, Ono K. What is optimal dual anti-platelet therapy duration after percutaneous coronary intervention? Eur Heart J Cardiovasc Pharmacother 2024; 10:10. [PMID: 37950560 DOI: 10.1093/ehjcvp/pvad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 10/28/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507 Kyoto, Japan
| | - Koji Hasegawa
- National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawahara-cho, Sakyo-ku, 606-8507 Kyoto, Japan
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Cortés P, Zeng JJ, Karime C, Lewis MD, Gharacholou SM, Antwi SO, Pang M. Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention. Gastrointest Endosc 2024; 99:10-20.e6. [PMID: 37579980 DOI: 10.1016/j.gie.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND AND AIMS The management of dual anti-platelet therapy after percutaneous coronary intervention (PCI) and GI bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of GIB and recurrent bleeding and to determine whether recurrent bleeding increases the risk of major adverse cardiovascular events (MACEs). METHODS In this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were GIB at 180 days and recurrent bleeding or MACE at 365 days. Logistic regression was used to identify predictors of GIB and recurrent bleeding. Cox proportional hazards modeling was used to determine whether recurrent bleeding can predict a MACE. RESULTS Five hundred thirty-six patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with a 95% increased odds of GIB (P < .001). The P2Y12 inhibitor was continued in >90% of patients, which trended toward significance for recurrent bleeding (P < .10). The HAS-BLED score (Hypertension, Abnormal renal and liver function, Stroke, Bleeding tendency or predisposition, Labile INRs, Elderly, Drugs), including a labile international normalized ratio and prior major bleeding, was strongly associated with recurrent bleeding (P ≤ .009). Recurrent bleeding was associated with a 115% increased risk of MACEs (P = .02). We derived a novel risk score, named the SIGE score ([S]TEMI at PCI, having a labile [I]NR at PCI, index [G]IB within 180 days of PCI, and previous precatheterization [E]ndoscopy within 6 months), to predict recurrent bleeding at 365 days with a high predictive accuracy (area under the curve, .773; 95% confidence interval, .702-.845). CONCLUSIONS The SIGE score may help to predict recurrent bleeding, which was shown to be associated with an increased risk of MACEs. Further external validation is needed.
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Affiliation(s)
- Pedro Cortés
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Jennifer J Zeng
- Krieger School of Arts & Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christian Karime
- Division of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michele D Lewis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Samuel O Antwi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Maoyin Pang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Zhou Y, He S, Hu Y. One year clinical outcome of dual anti-platelet therapy with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm: A meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107491. [PMID: 37988833 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The use of stents to treat un-ruptured intracranial aneurysms was first approved in the year 2002 in the United States as a Humanitarian Device Exemption. Antiplatelet therapy is mandatory following stent placement. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel has been the first line agents for the prevention of thromboembolic events following neuro-endovascular procedures. However, clopidogrel hypo-responsiveness has often been observed. In this analysis, we aimed to systematically compare one year clinical outcome of DAPT with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm. METHODS Online electronic databases were searched from June 2023 till July 2023 for relevant studies which compared DAPT with ticagrelor or clopidogrel for endovascular intervention in patients with intracranial aneurysm. The endpoints which were analyzed were classified into thromboembolic and hemorrhagic events. A fixed and a random effect statistical model were used during data analysis respectively. Risk ratio (RR) with 95 % confidence interval (CI) was used to represent the data following analysis. RESULTS Five studies with a total number of 893 participants were included in this analysis. Three hundred and fifty eight (358) participants were assigned to the ticagrelor group whereas 535 participants were assigned to clopidogrel group. Participants' enrollment period ranged from the year 2009 to 2019. Our results showed that during a mean follow-up time period of one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events with RR: 0.33, 95 % CI: 0.16 - 0.68; P = 0.003. In addition, at one year, DAPT with ticagrelor was not associated with any increase in hemorrhagic events (RR: 0.66, 95 % CI: 0.29 - 1.50; P = 0.32) when compared to DAPT with clopidogrel. CONCLUSION At one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events without any increase in hemorrhagic events when compared to clopidogrel associated DAPT for endovascular intervention of patients with intracranial aneurysm. However, even though ticagrelor-associated DAPT use appeared to be more effective and safe, this hypothesis should only be confirmed in larger upcoming trials.
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Affiliation(s)
- Yunxia Zhou
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, 310053, PR China
| | - Shenglan He
- Department of Pharmacy, Central People's Liberation Army Hospital, Wuhan, Hubei, 430014, PR China
| | - Yanhong Hu
- Department of Neurosurgery, Hangzhou Red Cross Hospital, Hangzhou, Zhejiang, 310000, PR China.
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Fujii T, Kasai S, Kawamura Y, Yoshimachi F, Ikari Y. Temporal variations in ischemic and bleeding event risks after acute coronary syndrome during dual antiplatelet therapy. Int J Cardiol 2023; 392:131340. [PMID: 37678433 DOI: 10.1016/j.ijcard.2023.131340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/22/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND This study estimates the temporal risk variations of ischemic and bleeding events during dual antiplatelet therapy (DAPT) among patients stratified according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria, suggesting the optimal period for DAPT after acute coronary syndrome (ACS). METHODS A total of 1264 ACS patients receiving either clopidogrel or prasugrel with aspirin were classified by ARC-HBR; HBR (n = 574) and non-HBR groups (n = 690). This study was designed as a multicenter observation to evaluate the primary endpoints of ischemic, including cardiovascular death, myocardial infarction, or ischemic stroke, and bleeding events, defined as Bleeding Academic Research Consortium type 3/5. The temporal risk variations were estimated using the Cox hazard and Royston-Parmar models. RESULTS Ischemic and bleeding events were observed in 9.4% and 7.4%, respectively, during an average observation period of 313 days. The HBR group had a higher incidence of both events than the non-HBR group (15.3% vs. 4.5%, P < 0.01 for ischemic; 11.9% vs. 3.8%, P < 0.01 for bleeding). The estimated risk curves for both events revealed peaks and steep declines in the first few days, followed by constant declines. The peak of risk was higher for bleeding than for ischemic events, but this relationship reversed early, with ischemic events displaying a higher risk in both the HBR and non-HBR groups until at least 60 days. CONCLUSIONS A 60-day period of DAPT is appropriate to balance the risks of adverse events after ACS, regardless of ARC-HBR criteria.
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Affiliation(s)
- Toshiharu Fujii
- Division of Cardiology, Tokai University School of Medicine, Isehara, Japan; Division of Cardiology, Tokai University Hachioji Hospital, Hachioji, Japan.
| | - Satoshi Kasai
- Division of Cardiology, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Yota Kawamura
- Division of Cardiology, Tokai University Hachioji Hospital, Hachioji, Japan
| | | | - Yuji Ikari
- Division of Cardiology, Tokai University School of Medicine, Isehara, Japan
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Mihatov N, Kirtane AJ, Stoler R, Feldman R, Neumann FJ, Boutis L, Tahirkheli N, Kereiakes DJ, Toelg R, Othman I, Stein B, Allocco D, Windecker S, Yeh RW. Bleeding and Ischemic Risk Prediction in Patients With High Bleeding Risk (an EVOLVE Short DAPT Analysis). Am J Cardiol 2023; 207:370-379. [PMID: 37778226 DOI: 10.1016/j.amjcard.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 10/03/2023]
Abstract
The EVOLVE Short DAPT study demonstrated the safety of truncated dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) treated with SYNERGY stent(s) (Boston Scientific Company, Marlborough, Massachusetts). In this population, bleeding and ischemic risk prediction may further inform DAPT decisions. This post hoc analysis of the EVOLVE Short DAPT study identified predictors of ischemic and bleeding events up to 15 months using Cox proportional hazard models. The predicted probabilities of bleeding were calculated using the Breslow method. Of 2,009 enrolled patients, 96.9% of the patients met at least 1 HBR criteria. At 15 months, the cumulative incidences of bleeding and ischemic events were 6.3% and 6.0%, respectively. The risk of bleeding was increased in patients who received oral anticoagulants (hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.50 to 3.36, p <0.001) or had peripheral vascular disease (HR 1.61, 95% CI 1.01 to 2.56, p = 0.045). The risk of ischemic events was increased in patients with diabetes (HR 1.86, 95% CI 1.24 to 2.78, p <0.01) or congestive heart failure (HR 2.06, 95% CI 1.39 to 3.04, p <0.001). Renal insufficiency/failure was associated with both endpoints. There was a strong positive correlation between the predicted probability of ischemic and bleeding events (R = 0.77, p <0.001). In 617 patients with a predicted bleeding risk <4%, ischemic events predominated, and the ischemic and bleeding rates were higher in patients with a predicted bleeding risk ≥4%. Within an HBR cohort, specific characteristics identify patients at a higher risk for ischemic and separately, bleeding events. Increased bleeding risk is tied to increased ischemic risk. In conclusion, standardized risk models are needed to inform DAPT decisions in patients with a higher risk. Clinical Trial Registration: NCT02605447.
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Affiliation(s)
- Nino Mihatov
- New York-Presbyterian Hospital - Brooklyn Methodist & Weill Cornell Medical College, New York, New York; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Robert Stoler
- Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | - Robert Feldman
- MediQuest Research at AdventHealth Ocala, Ocala, Florida
| | | | - Loukas Boutis
- North Shore University Hospital, Manhasset, New York
| | | | - Dean J Kereiakes
- Lindner Center for Research and Education at Christ Hospital, Cincinnati, Ohio
| | - Ralph Toelg
- Heart Center Segeberger Kliniken, Bad Segeberg, Germany
| | - Islam Othman
- Duke University Health System, Durham, North Carolina
| | - Bernardo Stein
- Morton Plant Mease Healthcare System, Clearwater, Florida
| | | | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
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Capodanno D, Greco A. Short Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months? JACC Cardiovasc Interv 2023; 16:2511-2513. [PMID: 37804285 DOI: 10.1016/j.jcin.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy.
| | - Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
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Woelders ECI, Luijkx JJP, Rodwell L, Winkler PJC, Dimitriu-Leen AC, Smits PC, van Royen N, Hof AWJV, Damman P, van Geuns RJM. Outcomes with P2Y12 inhibitor monotherapy after PCI according to bleeding risk: A Bayesian meta-analysis. Cardiovasc Revasc Med 2023; 55:44-51. [PMID: 37188619 DOI: 10.1016/j.carrev.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND P2Y12 inhibitor monotherapy is a promising novel strategy to reduce bleeding complications compared to dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI). In order to personalise treatment with DAPT based on patients' bleeding risk, we compared outcomes after PCI between P2Y12 inhibitor monotherapy and DAPT according to bleeding risk. METHODS A search for randomized clinical trials (RCTs) comparing P2Y12 inhibitor monotherapy after a short period of DAPT to standard DAPT after PCI was performed. Outcome differences between treatment groups regarding major bleedings, major adverse cardiac and cerebral events (MACCE) and net adverse clinical events (NACE) were assessed with hazard ratios (HRs) and corresponding credible intervals (CrI) according a Bayesian random effects model in patients with and without high bleeding risk (HBR). RESULTS Five RCTs including 30,084 patients were selected. P2Y12 inhibitor monotherapy compared to DAPT reduced major bleedings in the total population (HR: 0.65, 95 % CrI: 0.44 to 0.92). The HRs of the HBR and non-HBR subgroups showed a similar reduction of bleedings for monotherapy (HBR: HR 0.66, 95 % CrI: 0.25 to 1.74; non-HBR: HR 0.63, 95 % CrI: 0.36 to 1.09). No notable differences between treatments on MACCE and NACE were observed in either sub-group or in the total population. CONCLUSIONS Regardless of bleeding risk, P2Y12 inhibitor monotherapy is the favourable choice after PCI regarding major bleedings and does not increase ischemic events compared to DAPT. This suggests that bleeding risk is not decisive when considering P2Y12 inhibitor monotherapy.
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Affiliation(s)
- Eva C I Woelders
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jasper J P Luijkx
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Laura Rodwell
- Radboud Institute for Health Sciences, Health Evidence, Section Biostatistics, Nijmegen, the Netherlands
| | - Patty J C Winkler
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Arnoud W J Van't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Yan K, Zhu P, Tang X, Li Y, Li J, Yuan D, Yang W, Yang Y, Gao R, Xu B, Yuan J, Zhao X. Five-Year Prognostic Value of DAPT Score in Older Patients undergoing Percutaneous Coronary Intervention: A Large-Sample Study in the Real World. J Atheroscler Thromb 2023; 30:1057-1069. [PMID: 37258235 PMCID: PMC10406629 DOI: 10.5551/jat.64212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/24/2023] [Indexed: 06/02/2023] Open
Abstract
AIM The dual-antiplatelet therapy (DAPT) score is recommended for predicting the risk of ischemia and bleeding for patients undergoing percutaneous coronary intervention (PCI). This study aimed to investigate the long-term prognostic value of the DAPT score in older PCI patients. METHODS This study enrolled 10,724 consecutive patients who underwent PCI from January 2013 to December 2013 in Fu Wai hospital, among whom 2,981 (27.8%) were aged ≥ 65 years. The ischemic endpoint was major adverse cardiovascular and cerebrovascular events (MACCE, including myocardial infarction, all-cause death, and stroke). The bleeding endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. RESULTS After a 5-year follow-up, 256 (12.0%) MACCEs and 53 (2.5%) BARC 2, 3, or 5 bleeding occurred. The patients were divided into two groups according to the DAPT score: the low-score (<2, n=1,646) and high-score (≥ 2, n=485) group. Multivariate Cox regression revealed that the risk of MACCE was similar between the two groups [hazard ratio (HR): 1.214, 95% confidence interval (CI): 0.916-1.609, P=0.178], whereas the risk of bleeding was significantly higher in the high-score group than in the low-score group (HR: 2.447, 95% CI: 1.407-4.257, P=0.002). The DAPT score did not show prognostic value in MACCE [area under the receiver operating characteristic curve (AUROC), 0.534; 95% CI: 0.496-0.572, P=0.079]; however, it demonstrated a certain prognostic value in BARC 2, 3, or 5 bleeding (AUROC, 0.646; 95% CI: 0.573-0.719, P<0.001). CONCLUSION This study suggested that in older PCI patients, the DAPT score did not show predictive value for MACCE; however, it had a certain predictive value for 5-year BARC 2, 3, or 5 bleeding.
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Affiliation(s)
- Kailun Yan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pei Zhu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofang Tang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yulong Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawen Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Deshan Yuan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weixian Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueyan Zhao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Heindl B, Clarkson S, Parcha V, Dillon C, Narayan R, Usifo E, Hillegass W, Irvin MR, Arora P, Zhai G, Beasley M, Limdi N. Risk of Postdischarge Bleeding From Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Among US Black and White Adults. J Am Heart Assoc 2022; 11:e024412. [PMID: 36073636 PMCID: PMC9683679 DOI: 10.1161/jaha.121.024412] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
Background Dual antiplatelet therapy after percutaneous coronary intervention reduces myocardial infarctions but increases bleeding. The risk of bleeding may be higher among Black patients for unknown reasons. Bleeding risk scores have not been validated among Black patients. We assessed the difference in bleeding risk between Black and White patients along with the performance of the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti Platelet Therapy, Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients, and Academic Research Consortium for High Bleeding Risk scores among both groups. Methods and Results This was a single-center prospective study of patients who underwent percutaneous coronary intervention (2014-2019) and were followed for 1 year. The outcome was postdischarge Bleeding Academic Research Consortium 2 to 5 bleeding. Incidence rates were reported. Cox proportional hazards models measured the effect of self-reported Black race on bleeding and determined the predictors of bleeding among 19 a priori variables. The 3 risk scores were assessed among Black and White patients separately using the Harrell concordance index. Of 1529 included patients, 342 (22.4%) self-reported as being Black race. Unadjusted bleeding rates were 22.7 per 100 person-years among Black patients versus 16.3 among White patients (hazard ratio, 1.41 [95% CI, 1.00-2.00], P=0.052). Predictors of bleeding were age, glomerular filtration rate <30 mL/min per 1.73 m2, prior bleeding, ticagrelor or prasugrel use, and anticoagulant use. Among Black and White patients, respectively, the C-indexes were the following: 0.644 versus 0.600 for Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti Platelet Therapy (P<0.001 for both), 0.620 versus 0.612 for Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients (P=0.003 and P<0.001, respectively), and 0.600 versus 0.598 for Academic Research Consortium for High Bleeding Risk (P=0.006 and P<0.001, respectively). Conclusions The risk of dual antiplatelet therapy-associated postdischarge Bleeding Academic Research Consortium 2 to 5 bleeding was not significantly different between self-reported Black and White patients. Bleeding risk scores performed similarly among both groups.
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Affiliation(s)
- Brittain Heindl
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Stephen Clarkson
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Vibhu Parcha
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Chrisly Dillon
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
| | - Renuka Narayan
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
| | - Ebikere Usifo
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
| | - William Hillegass
- Department of Data Science, School of Public HealthUniversity of Mississippi Medical CenterJacksonMS
| | | | - Pankaj Arora
- Division of Cardiovascular Diseases, Department of MedicineUniversity of Alabama at BirminghamBirminghamAL
| | - Guihua Zhai
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAL
| | - Mark Beasley
- School of Public HealthUniversity of Alabama at BirminghamBirminghamAL
| | - Nita Limdi
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAL
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11
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Vranken NPA, Rasoul S, Luijkx JJP, Pustjens TFS, Postma S, Kolkman EJ, Kedhi E, Rifqi S, Lee MKY, Ebelt H, Merkely B, Verdoia M, Wojakowski W, van ’t Hof AAWJ, Suryapranata H, De Luca G. Short-term dual antiplatelet therapy in diabetic patients admitted for acute coronary syndrome treated with a new-generation drug-eluting stent. Diabetes Metab Res Rev 2022; 38:e3530. [PMID: 35395144 PMCID: PMC9541907 DOI: 10.1002/dmrr.3530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/07/2022] [Accepted: 03/09/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy (DAPT) in patients with diabetes mellitus (DM) admitted with acute coronary syndrome (ACS) and treated with a drug-eluting stent (DES) remains unclear. This is a prespecified sub-study from the Randomised Evaluation of short-term DUal antiplatelet therapy in patients with acute Coronary syndromE treated with a new generation DES (REDUCE) trial that was designed to determine the efficacy and safety of short-term versus standard 12 months DAPT in diabetic patients with ACS undergoing percutaneous coronary intervention (PCI) using the COMBO stent. METHODS In this study we included ACS diabetic patients enroled in the REDUCE trial treated with the COMBO stent and randomly assigned to either 3 or 12 months of DAPT. The primary study endpoint was the composite of all-cause mortality, myocardial infarction (MI), stent thrombosis (ST), stroke, target vessel revascularisation (TVR), and bleeding complications at 12 and 24 months follow-up. RESULTS A total of 307 diabetic patients were included, of which 162 (52.8%) in the 3 months DAPT group and 145 (47.2%) in the 12 months DAPT group. Patient characteristics, PCI success, and number of stents used were similar in the 3 and 12 months DAPT groups. Occurrence of the primary study endpoint at 12 and 24 months follow-up was comparable between the two groups (3.1 vs. 3.5%, p = 0.865, and 15.8 vs. 14.9%, p = 0.824, respectively). Moreover, the prevalence of the specific clinical outcome parameters (all-cause mortality), MI, ST, stroke, TVR, and bleeding was similar in both study groups. CONCLUSIONS This sub-analysis shows similar clinical outcomes following 3 months DAPT as compared to 12 months DAPT in diabetic patients undergoing PCI for ACS using the COMBO stent. These results suggest that, even in this particular subset of patients, short duration of DAPT might be considered safe. Future larger studies are warranted to provide more precise estimations in terms of safety and efficacy of short term DAPT in these high-risk patients.
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Affiliation(s)
| | - Saman Rasoul
- Department of CardiologyZuyderland Medical CentreHeerlenThe Netherlands
| | | | | | | | | | - Elvin Kedhi
- Department of CardiologyErasmus HospitalBrusselsBelgium
| | - Sodiqur Rifqi
- Department of CardiologyDr. Kariadi HospitalSemarangIndonesia
| | | | - Henning Ebelt
- Department of CardiologyCatholic Hospital of Johann NepomukErfurtGermany
| | - Béla Merkely
- Department of CardiologySemmelweis University Heart and Vascular CenterBudapestHungary
| | - Monica Verdoia
- Division of CardiologyOspedale degli Infermi, ASL BiellaBiellaItaly
- Division of Clinical and Experimental CardiologyAOU Sassari, University of SassariSassariItaly
| | | | - Arnoud A. W. J. van ’t Hof
- Department of CardiologyZuyderland Medical CentreHeerlenThe Netherlands
- Department of CardiologyIsalaZwolleThe Netherlands
| | - Harry Suryapranata
- Department of CardiologyRadboud University Medical CentreNijmegenThe Netherlands
| | - Giuseppe De Luca
- Division of Clinical and Experimental CardiologyAOU Sassari, University of SassariSassariItaly
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12
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Song PS, Ahn KT, Park JH, Kang DY, Park DW, Choi SW. Performance of Bleeding Risk Scores in Predicting Bleeding Complications in Korean Patients Who Are Receiving Dual Antiplatelet Therapy for Acute Coronary Syndrome. Am J Cardiol 2022; 165:131-132. [PMID: 34887072 DOI: 10.1016/j.amjcard.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Pil Sang Song
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Kye Taek Ahn
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Si Wan Choi
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, South Korea
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13
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Xiao FC, Ma WG, Ge YP, Zhu JM, Sun LZ. Does preoperative dual antiplatelet therapy affect bleeding and mortality after total arch repair for acute type A dissection? Interact Cardiovasc Thorac Surg 2022; 34:120-127. [PMID: 34999809 PMCID: PMC8923404 DOI: 10.1093/icvts/ivab226] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 08/30/2020] [Revised: 01/11/2021] [Accepted: 07/16/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Data are scarce and mixed regarding the impact of preoperative dual antiplatelet therapy (DAPT) on the surgical outcomes of acute type A aortic dissection (ATAAD). We seek to evaluate the impact of DAPT on bleeding-related events and early- and mid-term mortality after total arch replacement and frozen elephant trunk in such patients. METHODS This study comprised 48 ATAAD patients on preoperative DAPT and 418 without DAPT (the whole series, i.e. unmatched cohort), from which 45 matched pairs were selected by propensity score (matched cohort). Bleeding-related events (reoperation for bleeding, bleeding of ≥1500 ml within the first 12 h postoperatively or transfusion of ≥10 units of red blood cell or use of recombinant activated factor VII), operative mortality and mid-term survival were compared in the unmatched and matched cohorts. The impact of preoperative DAPT was evaluated with multivariable analysis. RESULTS In the unmatched cohort, bleeding of ≥1500 ml/12 h postoperatively was more common in the DAPT group (18.8% vs 8.4%, P = 0.020); operative mortality was 9.7%, which did not differ with DAPT (12.5% vs 9.3%, P = 0.48). Nor did bleeding-related events (54.2% vs 43.5%, P = 0.16) differ significantly between 2 groups. In the matched cohort, neither were drainage of ≥1500 ml/12 h (20% vs 6.7%, P = 0.063) and bleeding-related events (53.3% vs 42.2%, P = 0.30), nor operative mortality (13.8 vs 8.9%, P = 0.50) and mid-term survival (79.3% vs 76.4%, P = 0.93) significantly different between 2 groups. DAPT was not identified as a predictor for operative mortality [odd ratio (OR) 0.97, 95% confidence interval (CI) 0.31-3.08; P = 0.96; adjusted OR 1.28, 95% CI 0.22-7.20; P = 0.78] and bleeding-related events (OR 1.50, 95% CI 0.76-2.95; P = 0.24; adjusted OR 2.03, 95% CI 0.80-3.66; P = 0.14). CONCLUSIONS In patients with ATAAD undergoing total arch replacement and frozen elephant trunk, although preoperative DAPT led to more postoperative bleeding, it did not increase bleeding-related events nor operative mortality nor mid-term death. The results of this study imply that for patients with ATAAD, emergency surgical repair, even if as extensive as total arch repair, should not be contraindicated or delayed simply because of ongoing DAPT.
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Affiliation(s)
- Fu-Cheng Xiao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yi-Pen Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
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14
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Agewall S. Treatment with dual antiplatelet therapy after an acute coronary event may often be tailor-made for the patient. Eur Heart J Cardiovasc Pharmacother 2022; 8:1-3. [PMID: 34984441 DOI: 10.1093/ehjcvp/pvab078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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15
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Ahmad Y, Howard JP, Madhavan MV, Leon MB, Makkar RR. Single Versus Dual Antiplatelet Therapy After Transcatheter Aortic Valve Replacement: A Meta-Analysis of Randomized Clinical Trials. Cardiovasc Revasc Med 2022; 34:46-53. [PMID: 33514490 PMCID: PMC8814464 DOI: 10.1016/j.carrev.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Guidelines recommend dual antiplatelet therapy (DAPT) after transcatheter aortic valve replacement (TAVR) but guidelines predate the publication of the largest randomized trial. There have been few trials in the field to date, and with a small number of total patients; pooling their results may therefore be helpful. METHODS We systematically identified all randomized trials comparing SAPT to DAPT after TAVR. The primary endpoint was the risk of major bleeding. Secondary endpoints included all bleeding, life-threatening bleeding, stroke, myocardial infarction, death and cardiac death. RESULTS Four trials, randomizing 1086 participants, were eligible (541 randomized to SAPT and 545 randomized to DAPT). The weighted mean follow-up was 9.1 months. The risk of major bleeding was significantly increased after DAPT (relative risk (RR) 2.36, 95% confidence interval (CI) 1.27 to 4.40, P = 0.007). There was a similar increased risk for all bleeding (RR 1.65, 95% CI 1.24 to 2.19, P < 0.001), although not for life-threatening bleeding (RR 1.44, 95% CI 0.74 to 2.77, P = 0.282). There were no significant differences in the risk of stroke, myocardial infarction (MI), death or cardiac death. There was no heterogeneity observed for any endpoint (I2 = 0.0%). CONCLUSIONS DAPT after TAVR is associated with an increased risk of major bleeding and all bleeding. There is no evidence of a significant difference between DAPT or SAPT for the risks of stroke, MI, death or cardiac death. However, the total number of patients randomized is small and the duration of follow-up is short. Larger scale randomized trials with longer follow-up are required to assess for any potential differences in ischemic endpoints or mortality.
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Affiliation(s)
- Yousif Ahmad
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Martin B Leon
- Columbia University Medical Center, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
| | - Raj R Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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16
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Khan MS, Moustafa A, Azhar AZ, Khan AR, Ikram S. Aspirin-free strategy versus standard term dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Eur J Prev Cardiol 2021; 28:e25-e28. [PMID: 32469617 DOI: 10.1177/2047487320925623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mohammad Saud Khan
- Department of Medicine, The Miriam Hospital and Warren Alpert School of Brown University, USA
| | - Abdelmoniem Moustafa
- Department of Medicine, The Miriam Hospital and Warren Alpert School of Brown University, USA
| | | | | | - Sohail Ikram
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, USA
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17
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. Utility of a pharmacogenetic-driven algorithm in guiding dual antiplatelet therapy for patients undergoing coronary drug-eluting stent implantation in China. Eur J Clin Pharmacol 2021; 78:215-225. [PMID: 34636928 DOI: 10.1007/s00228-021-03224-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/15/2021] [Accepted: 09/15/2021] [Indexed: 11/27/2022]
Abstract
PURPOSES The POPular Risk Score (PRiS), a pharmacogenetic-driven algorithm consisting of CYP2C19 genotype, platelet reactivity, and clinical risk factors, is developed to evaluate ischemic risk and guide dual antiplatelet therapy (DAPT). This study aimed to evaluate the efficacy and safety of DAPT in accordance with the PRiS in patients undergoing drug-eluting stent (DES) implantation. METHODS A total of 1757 patients recruited in this cohort study were divided into four groups according to the PRiS and type of P2Y12 receptor inhibitor treatment at discharge. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis, and target vessel revascularization) during 1-year follow-up. The safety endpoints were defined by Bleeding Academic Research Consortium (BARC) criteria as major bleeding (BARC 3a, 3b, 3c, and 5) and clinically relevant bleeding (BARC 2, 3a, 3b, 3c, and 5). RESULTS Among 1046 patients with PRiS < 2 and 711 patients with PRiS ≥ 2, 34.2% and 38.3% of them were treated with ticagrelor, respectively. The PRiS ≥ 2 was an independent predictor for the 1-year incidence of MACE (HR(95%CI): 2.09 (1.37-3.20), p = 0.001). Multivariable Cox regression indicated that in the PRiS ≥ 2 group, ticagrelor was superior to clopidogrel in reducing the risk of MACE (HR(95%CI): 0.53 (0.29-0.98), p = 0.042), without increasing the bleeding risk. On the other hand, in the PRiS < 2 group, clopidogrel treatment was related to a remarkably lower rate of BARC class ≥ 2 bleeding (HR(95%CI): 0.39 (0.20-0.72), p = 0.003), but comparable incidences of MACE and BARC class ≥ 3 bleeding during 1-year follow-up. Similar associations between P2Y12 receptor inhibitors and 1-year endpoints in the PRiS < 2 and PRiS ≥ 2 group could also be identified in propensity score-weighted analysis and propensity score-matched analysis. CONCLUSION Tailored DAPT based on the PRiS could assist in improving the prognosis of patients undergoing DES implantation. Further randomized controlled trials are required to provide more evidence for PRiS-guided DAPT.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, People's Republic of China.
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Zhang H, Lin F, Zhao Y, Chang W, Liu H, Yin J, Li L. Assessing the Efficacy and Safety of Tirofiban in Combination With Dual-antiplatelet Therapy in Progressive Ischemic Stroke Patients. J Cardiovasc Pharmacol 2021; 78:448-452. [PMID: 34117180 DOI: 10.1097/fjc.0000000000001077] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT This study assessed the efficacy and safety of tirofiban in combination with dual-antiplatelet therapy (DAPT) in progressive ischemic stroke. One hundred and four patients equally divided into a tirofiban group or DAPT group were enrolled from June 2018 to December 2019. Efficacy outcomes included National Institutes of Health Stroke Scale score for 14 days, and modified Rankin scale (mRs) scores as excellent (mRs 0-1) or favorable (mRs 0-2) measured 90 days after stroke. At 14 days, the tirofiban group had a lower National Institutes of Health Stroke Scale score compared with the DAPT group (F = 14.959, P = 0.000). The mRS scores of the 2 groups at 90 days after treatment were significantly different from those before treatment. At 90 days, excellent favorable functional outcome (mRS ≤ 2) was achieved in 33 of 52 (63.43%) patients in the tirofiban group compared with 25 of 52 (48.08%) patients in the DAPT group. The incidence of bleeding was 5.77% in the tirofiban group, compared with 0% in DAPT group. Intravenous (IV) tirofiban alone or combined with DAPT was shown to be safe and effectively improved clinical outcome in progressive ischemic stroke patients. IV tirofiban was shown to be superior to the DAPT regimen.
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Affiliation(s)
- Haiqi Zhang
- Department of Neurology, the Second People's Hospital of Liaocheng City, the Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Shandong, China; and
| | - Feng Lin
- Department of Neurology, the Second People's Hospital of Liaocheng City, the Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Shandong, China; and
| | - Yanjun Zhao
- Department of Neurology, the Second People's Hospital of Liaocheng City, the Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Shandong, China; and
| | - Wansheng Chang
- Department of Neurology, the Second People's Hospital of Liaocheng City, the Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Shandong, China; and
| | - Hui Liu
- Department of Neurology, the Second People's Hospital of Liaocheng City, the Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Shandong, China; and
| | - Jijun Yin
- Department of Neurology, the Second People's Hospital of Liaocheng City, the Second Hospital of Liaocheng Affiliated to Shandong First Medical University, Shandong, China; and
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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19
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Trejo-Velasco B, Tello-Montoliu A, Cruz-González I, Moreno R, Baz-Alonso JA, Salvadores PJ, Romaguera R, Molina-Navarro E, Paredes-Galán E, Fernández-Barbeira S, Ortiz-Saez A, Bastos-Fernandez G, De Miguel-Castro A, Figueiras-Guzman A, Iñiguez-Romo A, Jimenez-Diaz VA. Impact of Comorbidities and Antiplatelet Regimen on Platelet Reactivity Levels in Patients Undergoing Transcatheter Aortic Valve Implantation. J Cardiovasc Pharmacol 2021; 78:463-473. [PMID: 34117181 DOI: 10.1097/fjc.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/12/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT The aim of our study is to assess the impact of anemia, chronic kidney disease, and diabetes mellitus on platelet reactivity (PR) in patients with severe aortic stenosis, both at baseline and after transcatheter aortic valve implantation (TAVI). This study is a prespecified subanalysis of the REAC-TAVI prospective, multicenter trial that included patients pretreated with aspirin + clopidogrel before TAVI. PR was measured at baseline and at 5 different time points after TAVI with the VerifyNow assay (Accriva Diagnostics, San Diego, CA), over a 3-month follow-up period. Patients with high PR (HPR) at baseline, before TAVI (n = 48) were randomized to aspirin + clopidogrel or aspirin + ticagrelor for 3 months, whereas those with normal PR (NPR) (n = 20) were continued on aspirin + clopidogrel. A "raiser response" in PR was defined as an increase in PR units >20% of baseline after TAVI. Patients with HPR before TAVI presented concomitant anemia and chronic kidney disease more frequently than their counterparts with NPR. Anemia and higher body mass index were independently associated with HPR to clopidogrel at baseline. Moreover, anemic patients with baseline HPR who were continued on clopidogrel presented higher PR after TAVI than patients with HPR switched to ticagrelor. All patients with baseline NPR presented a "raiser response" after TAVI, which was nonexistent among patients with HPR managed with ticagrelor. In summary, anemia seems as a relevant factor associated with baseline HPR and higher PR after TAVI in patients with baseline HPR randomized to clopidogrel, whereas ticagrelor proved more effective than clopidogrel at attaining sustained reductions in PR during follow-up, regardless of baseline comorbidities.
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Affiliation(s)
- Blanca Trejo-Velasco
- Cardiology Department, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - Antonio Tello-Montoliu
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
| | - Ignacio Cruz-González
- Cardiology Department, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
| | - Raul Moreno
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
- Interventional Cardiology, Instituto de Investigación del Hospital La Paz (IDIPAZ), University Hospital La Paz, Madrid, Spain
| | - Jose A Baz-Alonso
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | - Pablo J Salvadores
- Cardiovascular Research Unit, Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
| | - Rafael Romaguera
- Cardiology Department, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Emilio Paredes-Galán
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | | | - Alberto Ortiz-Saez
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | | | | | - Adolfo Figueiras-Guzman
- Departamento de Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad de Santiago de Compostela
| | - Andres Iñiguez-Romo
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | - Victor A Jimenez-Diaz
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Unit, Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
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Kao CC, Wu MS, Chuang MT, Lin YC, Huang CY, Chang WC, Chen CW, Chang TH. Investigation of dual antiplatelet therapy after coronary stenting in patients with chronic kidney disease. PLoS One 2021; 16:e0255645. [PMID: 34347826 PMCID: PMC8336855 DOI: 10.1371/journal.pone.0255645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background Dual antiplatelet therapy (DAPT) is currently the standard treatment for the prevention of ischemic events after stent implantation. However, the optimal DAPT duration remains elusive for patients with chronic kidney disease (CKD). Therefore, we aimed to compare the effectiveness and safety between long-term and short-term DAPT after coronary stenting in patients with CKD. Methods This retrospective cohort study analyze data from the Taipei Medical University (TMU) Institutional and Clinical Database, which include anonymized electronic health data of 3 million patients that visited TMU Hospital, Wan Fang Hospital, and Shuang Ho Hospital. We enrolled patients with CKD after coronary stenting between 2008 and 2019. The patients were divided into the long-term (>6 months) and short-term DAPT group (≤ 6 months). The primary end point was major adverse cardiovascular events (MACE) from 6 months after the index date. The secondary outcomes were all-cause mortality and Thrombolysis in Myocardial Infarction (TIMI) bleeding. Results A total of 1899 patients were enrolled; of them, 1112 and 787 were assigned to the long-term and short-term DAPT groups, respectively. Long-term DAPT was associated with similar risk of MACE (HR: 1.05, 95% CI: 0.65–1.70, P = 0.83) compare with short-term DAPT. Different CKD risk did not modify the risk of MACE. There was also no significant difference in all-cause mortality (HR: 1.10, 95% CI: 0.75–1.61, P = 0.63) and TIMI bleeding (HR 1.19, 95% CI: 0.86–1.63, P = 0.30) between groups. Conclusions Among patients with CKD and coronary stenting, we found that long-term and short-term DAPT tied on the risk of MACE, all-cause mortality and TIMI bleeding.
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Affiliation(s)
- Chih-Chin Kao
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Urology and Kidney (TMU-RCUK), Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ming-Tsang Chuang
- Clinical Data Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Yi-Cheng Lin
- Department of Pharmacy, Taipei Medical University Hospital, Taipei, Taiwan
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yao Huang
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart institute, Taipei Medical University, Taipei, Taiwan
| | - Wei-Chiao Chang
- Division of Nephrology, Department of Internal Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Clinical Pharmacy, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Master Program for Clinical Pharmacogenomics and Pharmacoproteomics, School of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chih-Wei Chen
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- Taipei Heart institute, Taipei Medical University, Taipei, Taiwan
- * E-mail:
| | - Tzu-Hao Chang
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan
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21
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Valgimigli M, Gragnano F, Branca M, Franzone A, Baber U, Jang Y, Kimura T, Hahn JY, Zhao Q, Windecker S, Gibson CM, Kim BK, Watanabe H, Song YB, Zhu Y, Vranckx P, Mehta S, Hong SJ, Ando K, Gwon HC, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Jüni P, Mehran R. P2Y12 inhibitor monotherapy or dual antiplatelet therapy after coronary revascularisation: individual patient level meta-analysis of randomised controlled trials. BMJ 2021; 373:n1332. [PMID: 34135011 PMCID: PMC8207247 DOI: 10.1136/bmj.n1332] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the risks and benefits of P2Y12 inhibitor monotherapy compared with dual antiplatelet therapy (DAPT) and whether these associations are modified by patients' characteristics. DESIGN Individual patient level meta-analysis of randomised controlled trials. DATA SOURCES Searches were conducted in Ovid Medline, Embase, and three websites (www.tctmd.com, www.escardio.org, www.acc.org/cardiosourceplus) from inception to 16 July 2020. The primary authors provided individual participant data. ELIGIBILITY CRITERIA Randomised controlled trials comparing effects of oral P2Y12 monotherapy and DAPT on centrally adjudicated endpoints after coronary revascularisation in patients without an indication for oral anticoagulation. MAIN OUTCOME MEASURES The primary outcome was a composite of all cause death, myocardial infarction, and stroke, tested for non-inferiority against a margin of 1.15 for the hazard ratio. The key safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or type 5 bleeding. RESULTS The meta-analysis included data from six trials, including 24 096 patients. The primary outcome occurred in 283 (2.95%) patients with P2Y12 inhibitor monotherapy and 315 (3.27%) with DAPT in the per protocol population (hazard ratio 0.93, 95% confidence interval 0.79 to 1.09; P=0.005 for non-inferiority; P=0.38 for superiority; τ2=0.00) and in 303 (2.94%) with P2Y12 inhibitor monotherapy and 338 (3.36%) with DAPT in the intention to treat population (0.90, 0.77 to 1.05; P=0.18 for superiority; τ2=0.00). The treatment effect was consistent across all subgroups, except for sex (P for interaction=0.02), suggesting that P2Y12 inhibitor monotherapy lowers the risk of the primary ischaemic endpoint in women (hazard ratio 0.64, 0.46 to 0.89) but not in men (1.00, 0.83 to 1.19). The risk of bleeding was lower with P2Y12 inhibitor monotherapy than with DAPT (97 (0.89%) v 197 (1.83%); hazard ratio 0.49, 0.39 to 0.63; P<0.001; τ2=0.03), which was consistent across subgroups, except for type of P2Y12 inhibitor (P for interaction=0.02), suggesting greater benefit when a newer P2Y12 inhibitor rather than clopidogrel was part of the DAPT regimen. CONCLUSIONS P2Y12 inhibitor monotherapy was associated with a similar risk of death, myocardial infarction, or stroke, with evidence that this association may be modified by sex, and a lower bleeding risk compared with DAPT. REGISTRATION PROSPERO CRD42020176853.
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Affiliation(s)
- Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- Contributed equally
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
- Contributed equally
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Charles M Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenji Ando
- Kokura Memorial Hospital, Department of Cardiology, Kitakyushu, Japan
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, Netherlands
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dik Heg
- Clinical Trials Unit, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Contributed equally
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Contributed equally
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Nardin M, Verdoia M, Gioscia R, Negro F, De Luca G. Impact of renin angiotensin system inhibitors on homocysteine levels and platelets reactivity in patients on dual antiplatelet therapy. Nutr Metab Cardiovasc Dis 2021; 31:1276-1285. [PMID: 33549433 DOI: 10.1016/j.numecd.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Dual antiplatelet therapy (DAPT) and Renin-angiotensin system inhibitors (RASi) represent the cornerstone in the treatment of patients undergoing percutaneous coronary interventions (PCI), mainly after an acute ischemic event. However, high-on treatment residual platelet reactivity (HRPR), is not infrequent despite optimal medical treatment. Homocysteine (Hcy) is a metabolite of methionine catabolism linked to atherothrombosis. Recently, a potential crosstalk between RAS and Hcy has been suggested, potentially favouring platelet aggregation and cardiovascular disease.Therefore, we aimed to investigate the impact of RASi on Hcy levels and platelet aggregation in patients on DAPT after PCI. METHODS AND RESULTS Patients undergoing PCI on DAPT with ASA plus an ADP-antagonist (clopidogrel, ticagrelor or prasugrel), were included. RASi comprised angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). Aggregation tests were performed by Multiple Electrode Aggregometry. We included 1210 patients, of whom 862 (71.2%) were on treatment with RASi. Overall, DAPT composition was ASA+clopidogrel in 566 (46.8%) patients, ASA+ticagrelor in 428 (35.4%) and ASA+prasugrel in 216 (17.9%). Median values of Hcy were higher in RASi patients (p = 0.006), who displayed a higher percentage of Hcy above the median value (52.4% vs. 44.8%, p = 0.019, adjustedOR [95%CI] = 1.40 [1.04-1.88], p = 0.027). No differences in HRPR rate were found according to RASi use for ASPI test (3.6% vs. 3.3%, p = 0.88) and ADP test (25.6% vs. 24.3%,p = 0.62; adjustedOR [95%CI] = 1.23 [0.89-1.70], p = 0.220) and according to ADP-antagonist type. A direct linear relationship was observed between platelet reactivity and Hcy in both patients receiving RASi and untreated ones, with higher values of platelet aggregation being observed in patients with Hcy above the median, independently from RASi administration and DAPT strategy. CONCLUSION In patients on DAPT after PCI, RASi treatment did not emerge as an independent predictor of HRPR. However, the levels of Hcy were significantly elevated in patients on RASi and related to higher values of platelet reactivity, independently from the DAPT strategy.
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Affiliation(s)
- Matteo Nardin
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Department of Medicine, ASST "Spedali Civili", University of Brescia, Brescia, Italy
| | - Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Division of Cardiology, "Ospedale degli Infermi", Biella, Italy
| | - Rocco Gioscia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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23
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Kang H, Zhou Y, Luo B, Lv N, Zhang H, Li T, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X, Liu J. Pipeline Embolization Device for Intracranial Aneurysms in a Large Chinese Cohort: Complication Risk Factor Analysis. Neurotherapeutics 2021; 18:1198-1206. [PMID: 33447904 PMCID: PMC8423892 DOI: 10.1007/s13311-020-00990-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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] [Accepted: 12/08/2020] [Indexed: 10/22/2022] Open
Abstract
During intracranial aneurysm embolization with the Pipeline embolization device (PED), ischemic and hemorrhagic complications have been observed in cases among Western populations. The postmarket multicenter registry study on the embolization of intracranial aneurysms with the PED in China, i.e., the PLUS study, was performed to assess real-world predictors of complications and functional outcomes in patients treated with the PED in a Chinese population. All patients with intracranial aneurysms who underwent embolization using the PED between November 2014 and October 2019 across 14 centers in China were included. The study endpoints included preoperative and early postoperative (< 30 days) functional outcomes (modified Rankin scale [mRS] scores) and complications related to PED treatment at early postoperative and follow-up time points (3-36 months). Multivariate analysis was performed to identify risk factors for complications. A total of 1171 consecutive patients (mean age, 53.9 ± 11.4; female, 69.6% [813/1171]) with 1322 aneurysms were included in the study. Hypertension, basilar artery aneurysms, and successful deployment after adjustment or unsuccessful device deployment were found to be independent predictors of ischemic stroke, while the use of the Flex PED and incomplete occlusion immediately after treatment were protective factors. An aneurysm size > 10 mm, distal anterior circulation aneurysms, and adjunctive coiling were found to be independent predictors of delayed aneurysm rupture, distal intraparenchymal hemorrhage, and neurological compression symptoms, respectively. The rate of PED-related complications in the PLUS study was similar to that in Western populations. The PLUS study identified successful deployment after adjustment or unsuccessful device deployment and the degree of immediate postoperative occlusion as novel independent predictors of PED-related ischemic stroke in a Chinese population. ClinicalTrial.gov Identifier: NCT03831672.
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Affiliation(s)
- Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100050, China
| | - Yu Zhou
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Bin Luo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100050, China
| | - Nan Lv
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People's Hospital, Zhengzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Uruqi, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100050, China.
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China.
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Sanchez F, Boasi V, Vercellino M, Tacchi C, Cannarile P, Pingelli N, Perri D, Gomez L, Cattunar S, Mascelli G. Risk definition and outcomes with the application of the PEGASUS-TIMI 54 trial inclusion criteria to a "real world" STEMI population: results from the Italian "CARDIO-STEMI SANREMO" registry. BMC Cardiovasc Disord 2021; 21:144. [PMID: 33736607 PMCID: PMC7977291 DOI: 10.1186/s12872-020-01780-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 11/09/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The PEGASUS-TIMI 54 trial inclusion criteria effectively identified high-risk patients with recent myocardial infarction (MI) who would benefit from continuing dual antiplatelet therapy (DAPT) with ticagrelor for more than 12 months. It is unknown how many real-world patients meet these criteria during the acute phase of ST-elevation MI (STEMI), or the extent to which these criteria predict a patient's risk and prognosis. Study objectives were: (1) determine the proportion of PEGASUS-TIMI 54-like patients (PG-l) in a real-world cohort of patients hospitalized with STEMI and to assess their ischemic and hemorrhagic risk; (2) examine their ischemic and hemorrhagic in-hospital events (major adverse cardiovascular and cerebrovascular events [MACCE] and clinically relevant bleeding); (3) evaluate their long-term outcomes and the impact on the long-term prognosis of the type of DAPT prescribed at discharge. METHODS This observational study was conducted in 1086 patients admitted to hospital with a diagnosis of STEMI between February 2011 and March 2018 and enrolled in the CARDIO-STEMI Sanremo registry. Patients' demographic and clinical characteristics, procedural variables, and individual ischemic and hemorrhagic risk scores were assessed in-hospital. Four-year survival was also analyzed. RESULTS The proportion of PG-I patients was 69.2%. Compared with non-PG-l patients, PG-l patients were older, had more multivessel disease and comorbidities, and experienced more frequent MACCE (8.3% vs. 3.6%, p = 0.005) and clinically significant bleeding events (6.7% vs. 2.7%, p = 0.008), a higher rate of in-hospital death (6.5% vs. 1.5%, p < 0.001), and higher follow-up mortality rate (14.8% vs. 7.7%; p = 0.002). Four-year survival was significantly lower in the PG-l group (83.9% vs. 91.8%; Log-rank = 0.001) and was related to the cumulative number of concurrent risk factors. In the unadjusted analysis, survival was greater in patients discharged on ticagrelor than on another P2Y12 inhibitor (90.2% vs. 76.7%, Log-rank = 0.001), and the difference was particularly evident in PG-l patients. CONCLUSIONS The risk of MACCE for PG-l patients increased with the number of concurrent PEGASUS-TIMI 54 risk features. Treatment with ticagrelor on discharge was associated with improved survival rates during 4 years of follow-up.
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Affiliation(s)
- Federico Sanchez
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Valentina Boasi
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy.
| | - Matteo Vercellino
- ASO Alessandria-Ospedale Civile SS. Antonio, Biagio e Cesare Arrigo, Alessandria, AL, Italy
| | - Chiara Tacchi
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Pierpaolo Cannarile
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Nicoletta Pingelli
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Dino Perri
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Laura Gomez
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Stefano Cattunar
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
| | - Giovanni Mascelli
- Department of Cardiology, UTIC Ospedale Civile Di Sanremo, ASL1 imperiese, via Giovanni Borea 56, 18038, Sanremo, IM, Italy
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Ayoub A, Ayinapudi K, Al-Ogaili A, Panhwar MS, Dakkak W, LeJemtel T. Toward Brief Dual Antiplatelet Therapy and P2Y12 Inhibitors for Monotherapy After PCI. Am J Cardiovasc Drugs 2021; 21:153-163. [PMID: 32780215 DOI: 10.1007/s40256-020-00430-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention remains a controversial topic. The European Society of Cardiology and the American College of Cardiology/American Heart Association recommend at least 6 and 12 months of DAPT after PCI in patients with stable coronary artery disease or acute coronary syndrome, respectively. Although prolonging DAPT duration reduces ischemic events, it is associated with higher rates of bleeding and possible fatal outcomes. The DAPT score can be an important tool to identify patients who may still benefit from prolonged therapy. Nevertheless, several recent randomized controlled trials showed that shortening DAPT duration from 12 to 1-3 months reduces bleeding rates without significantly increasing ischemic event rates. These trials also suggested replacing acetylsalicylic acid (aspirin) with P2Y12 inhibitors after short-term DAPT. We review and compare past and present studies regarding DAPT and analyze the evidence favoring a short DAPT duration and the long-term single antiplatelet agent of choice.
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Affiliation(s)
- Ali Ayoub
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA.
| | - Karnika Ayinapudi
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| | - Ahmed Al-Ogaili
- Department of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Muhammad Siyab Panhwar
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| | - Wael Dakkak
- Department of Medicine, Southern Illinois University, Springfield, IL, USA
| | - Thierry LeJemtel
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
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Alkhalil M, Edwards R, Puri R, Kalra A, Zaman A, Das R. Aspirin Versus Dual Antiplatelet Therapy in Patients Undergoing Trans-Catheter Aortic Valve Implantation, Updated Meta-Analysis. Cardiovasc Drugs Ther 2021; 36:279-283. [PMID: 33587229 DOI: 10.1007/s10557-021-07146-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The Antiplatelet Therapy for Patients Undergoing Transcatheter Aortic-Valve Implantation (POPular TAVI) trial reported comparable composite endpoints of ischemic events using aspirin compared to dual antiplatelet therapy (DAPT). However, this trial was not powered to detect individual differences in ischemic events. We sought to conduct a meta-analysis to compare aspirin to DAPT on ischemic and bleeding events following TAVI. METHODS The MEDLINE database was searched from inception until September 2020 and only randomized clinical trials of patients receiving antiplatelet therapy following TAVI were included. The treatment effect was reported as rate ratios (RRs) with 95% confidence intervals. RESULTS Four randomized clinical trials of 1086 TAVI patients were included. There was a 51% reduction in major or life-threatening bleeding with aspirin compared with DAPT [RR 0.49, (95%CI 0.31 to 0.78)]. Aspirin was not associated with an increased risk of death [RR 1.01, (95%CI 0.62 to 1.65)], cardiovascular death [RR 1.15, (95%CI 0.56 to 2.36)], ischemic stroke [RR 0.93, (95%CI 0.51 to 1.70)], or MI [RR 0.53, (95%CI 0.18 to 1.57)]. CONCLUSIONS This meta-analysis supports the use of aspirin as the optimal antiplatelet strategy following TAVI procedures in reducing bleeding without an increase in ischemic events compared with dual antiplatelet therapy.
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Affiliation(s)
- Mohammad Alkhalil
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, UK.
| | - Richard Edwards
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, UK
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Azfar Zaman
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, UK
- Newcastle University, Newcastle-upon-Tyne, UK
| | - Rajiv Das
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, UK
- Northumbria University, Newcastle upon Tyne, UK
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Johnson TW, Baos S, Collett L, Hutchinson JL, Nkau M, Molina M, Aungraheeta R, Reilly‐Stitt C, Bowles R, Reeves BC, Rogers CA, Mundell SJ, Baumbach A, Mumford AD. Pharmacodynamic Comparison of Ticagrelor Monotherapy Versus Ticagrelor and Aspirin in Patients After Percutaneous Coronary Intervention: The TEMPLATE (Ticagrelor Monotherapy and Platelet Reactivity) Randomized Controlled Trial. J Am Heart Assoc 2020; 9:e016495. [PMID: 33305660 PMCID: PMC7955396 DOI: 10.1161/jaha.120.016495] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background To assess differences in platelet inhibition during ticagrelor monotherapy (TIC) or dual therapy with ticagrelor and aspirin (TIC+ASP) in patients after percutaneous coronary intervention using a comprehensive panel of functional tests. Methods and Results In a single‐center parallel group, open label, randomized controlled trial, 110 participants were randomized to receive either TIC (n=55) or TIC+ASP (n=55) for 4 weeks. The primary outcome was the platelet aggregation response with 10 μmol/L thrombin receptor activation peptide‐6 (TRAP‐6). The secondary outcomes were platelet aggregation responses and binding of surface activation markers with a panel of other activators. The mean percentage aggregation for 10 μmol/L TRAP‐6 was similar for the TIC and TIC+ASP groups (mean difference+4.29; 95% CI, −0.87 to +9.46). Aggregation was higher in the TIC group compared with the TIC+ASP group with 1 μg/mL (+6.47; +2.04 to +10.90) and 0.5 μg/mL (+14.00; +7.63 to +20.39) collagen related peptide. Aggregation responses with 5 μmol/L TRAP‐6, 5 μmol/L or 2.5 μmol/L thromboxane A2 receptor agonist and surface activation marker binding with 5 μmol/L TRAP‐6 or 0.5 μg/mL collagen related peptide were the same between the treatment groups. Conclusions Patients with PCI show similar levels of inhibition of most platelet activation pathways with TIC compared with dual therapy with TIC + ASP. However, the greater aggregation response with collagen related peptide during TIC indicates incomplete inhibition of glycoprotein VI (collagen) receptor‐mediated platelet activation. This difference in pharmacodynamic response to anti‐platelet medication may contribute to the lower bleeding rates observed with TIC compared with dual antiplatelet therapy in recent clinical trials. Registration Information URL: https://www.isrctn.com; Unique Identifier ISRCTN84335288.
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Affiliation(s)
- Thomas W. Johnson
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Sarah Baos
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Laura Collett
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - James L. Hutchinson
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | - Martin Nkau
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Maria Molina
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Riyaad Aungraheeta
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | | | - Ruth Bowles
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
| | - Barnaby C. Reeves
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Chris A. Rogers
- Clinical Trials and Evaluation UnitBristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Stuart J Mundell
- School of Physiology, Pharmacology and NeuroscienceUniversity of BristolBristolUK
| | - Andreas Baumbach
- William Harvey Research InstituteQueen Mary University of LondonLondonUK
| | - Andrew D. Mumford
- Bristol Heart InstituteUniversity Hospitals Bristol & Weston NHS Foundation TrustBristolUK
- School of Cellular and Molecular MedicineUniversity of BristolBristolUK
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Wang HY, Dou KF, Yin D, Xu B, Zhang D, Gao RL. Risk/Benefit Tradeoff of Prolonging Dual Antiplatelet Therapy More Than 12 Months in TWILIGHT-Like High-Risk Patients After Complex Percutaneous Coronary Intervention. Am J Cardiol 2020; 133:61-70. [PMID: 32811654 DOI: 10.1016/j.amjcard.2020.07.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 12/28/2022]
Abstract
Patients who underwent complex percutaneous coronary intervention (PCI) are known to be at high risk for both ischemic and bleeding complications. The risk/benefit tradeoff of extending dual antiplatelet therapy (DAPT) >12 months with clopidogrel and aspirin for TWILIGHT-like patients who are at high risk of bleeding or ischemic events and undergo complex PCI is unclear. Eight thousand three hundred and fifty-eight consecutive patients fulfilling the "TWILIGHT-like" criteria who underwent PCI from January 2013 to December 2013 were prospectively enrolled in Fuwai PCI Registry. We identified 2,677 of "TWILIGHT-like" complex PCI patients who were events free at 1 year after the index procedure. "TWILIGHT-like" patients were identified based on at least 1 clinical and 1 angiographic feature. Median follow-up was 29 months. Risk of primary efficacy outcome, major adverse cardiac and cerebrovascular events (composite of all-cause death, myocardial infarction, or stroke), was reduced with DAPT >12 months versus DAPT≤ 12 months (hazard ratio [HR]adj 0.374, 95% confidence interval [CI] 0.235 to 0.595; HRmatched 0.292 [0.151 to 0.561]; HRIPTW 0.356 [0.225 to 0.562]), with directional consistency for cardiovascular death and definite/probable stent thrombosis. In contrast, >12-month DAPT was comparable to ≤12-month DAPT for the risk of clinically relevant bleeding ([HR]adj 1.189, 95% CI 0.474 to 2.984; HRmatched 1.577 [0.577 to 4.312]; HRIPTW 1.239 [0.502 to 3.059]). Importantly, there was also a significant net benefit in favor of prolonged DAPT treatment. In conclusion, among "TWILIGHT-like" patients after complex PCI, continuing duration of DAPT> 12 months was associated with a net clinical benefit and lower rates of ischemic events without increasing the risk of clinically relevant bleeding than DAPT≤ 12 months, suggesting that long-term DAPT may have a favorable risk-benefit ratio in this high-risk population.
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Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; State Key Laboratory of Cardiovascular Disease, Beijing, China; National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ke-Fei Dou
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; State Key Laboratory of Cardiovascular Disease, Beijing, China; National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Dong Yin
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China; Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Zhang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; State Key Laboratory of Cardiovascular Disease, Beijing, China; National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Fu-Sang W, Xiao-Han Z, Yang Z, Ting-Ting C, Chao S, Jing-Yi L, Jian-Jun Z. Efficacy and safety of dual versus mono antiplatelet therapy in patients with stroke or transient ischemic attack: An updated meta-analysis of 18 randomized controlled trials. Pharmazie 2020; 75:516-523. [PMID: 33305729 DOI: 10.1691/ph.2020.0683] [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: 06/12/2023]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) as a routine treatment in stroke patients is still controversial. The efficacy and safety of DAPT may vary with different regiments, initiating treatment time and race. Our study assessed the efficacy and safety of DAPT in patients with stroke and to determine the factors influencing the efficacy and safety of DAPT. Relevant studies published up to May 2019 from PubMed, Embase, Web of Science and the Cochrane Library. Randomized controlled trials comparing DAPT with mono antiplatelet therapy (MAPT) for stroke secondary prevention were included. The primary endpoints were stroke recurrence, ischemic stroke recurrence and all-cause death. Subgroup analysis was made according to regiment, initiating treatment time and race. Eighteen studies (n=33353) were included. Comparing with MAPT, short-term DAPT reduced stroke recurrence (RR = 0.68, 95% CI = 0.60-0.77) and ischemic stroke recurrence (RR = 0.67, 95% CI = 0.59-0.77) but increased major bleeding (RR = 1.82, 95% CI = 1.11-2.98). Long-term DAPT had no superiority compared with MAPT. Aspirin plus clopidogrel comparing with aspirin and early initiating treatment time comparing with MAPT decreased stroke recurrence (RR = 0.74, 95% CI = 0.67-0.83; RR = 0.69, 95% CI = 0.61-0.78) and ischemic stroke recurrence ( RR = 0.71, 95% CI = 0.64-0.79; RR = 0.68, 95% CI = 0.59-0.77) but also increased major bleeding (RR = 1.70, 95% CI = 1.38-2.09; RR = 1.75, 95% CI = 1.07-2.85). DAPT reduced stroke and ischemic stroke recurrence in non-Asian group but only reduced ischemic stroke recurrence in Asian group. As stroke secondary prevention, short-term DAPT rather than long-term DAPT could be a better choice. Patients could benefit more from aspirin plus clopidogrel or given DAPT within 72 h after symptoms onset. Race may be a factor influencing the efficacy of DAPT.
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Affiliation(s)
- Wang Fu-Sang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zheng Xiao-Han
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zou Yang
- Faculty of Science, Melbourne University, Melbourne, Australia
| | - Chen Ting-Ting
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Sun Chao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Ling Jing-Yi
- Institute for Laboratory Medicine, NO.900 Hospital of the Joint Logistics Team of PLA, Fuzhou, China;,
| | - Zou Jian-Jun
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China;,
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Kwok CS, Wong CW, Nagaraja V, Mamas MA. A systematic review of the studies that evaluate the performance of the DAPT score. Int J Clin Pract 2020; 74:e13591. [PMID: 32562449 DOI: 10.1111/ijcp.13591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The Dual Antiplatelet Therapy (DAPT) score was derived to determine which patients may benefit from prolonged DAPT therapy after 12 months based on the balance between ischaemic and bleeding events. Several studies have attempted to validate the score with inconsistent findings. METHODS We conducted a systematic review of the studies that evaluated the DAPT score in PCI populations. A search was performed on MEDLINE and EMBASE and two independent reviewers reviewed the search results for study inclusion and extracted data from studies which met the inclusion criteria. Data are presented in tables and narrative synthesis was performed. RESULTS A total of 13 studies were included in this review. The study designs included post hoc analysis of randomised trials, prospective cohorts, retrospective cohorts and a case-control study. In the derivation/validation study, the c-statistic for ischaemic and bleeding outcomes were 0.64/0.70 and 0.68/0.64, respectively. Among the validation studies, the C-statistics for composite outcomes ranged from 0.53 to 0.71 for ischaemic outcomes and 0.49 to 0.71 for bleeding outcomes. Only one study randomised patients with high DAPT score to different combinations of antiplatelet after 1 year of DAPT and found that continuation of DAPT was associated with fewer deaths because of myocardial infarction, but more bleeding. CONCLUSIONS While not designed for this purpose many studies have shown that the DAPT score has modest predictive value for ischaemic and bleeding outcomes. A prospective randomised controlled trial is needed to evaluate the clinical benefits of utilising the DAPT score in guiding continued DAPT therapy beyond 1 year.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Chun Wai Wong
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Vinayak Nagaraja
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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Krackhardt F, Waliszewski M, Kočka V, Toušek P, Janek B, Hudec M, Lozano F, Roman KGS, Del Blanco BG, Mauri J, Heang TM, Ahn TH, Jeong MH, Herberger D, Tomulic V, Levy G, Sebagh L, Rischner J, Pansieri M. Real-World Dual Antiplatelet Therapy Following Polymer-Free Sirolimus-Eluting Stent Implantations to Treat Coronary Artery Disease. Cardiovasc Drugs Ther 2020; 34:335-344. [PMID: 32212061 PMCID: PMC8626401 DOI: 10.1007/s10557-020-06963-5] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objectives The objective of this post hoc analysis was to analyze real-world dual antiplatelet therapy (DAPT) regimens following polymer-free sirolimus-eluting stent (PF-SES) implantations in an unselected patient population. Methods Patient-level data from two all-comers observational studies (ClinicalTrials.gov Identifiers: NCT02629575 and NCT02905214) were pooled and analyzed in terms of their primary endpoint. During the data verification process, we observed substantial deviations from DAPT guideline recommendations. To illuminate this gap between clinical practice and guideline recommendations, we conducted a post hoc analysis of DAPT regimens and clinical event rates for which we defined the net adverse event rate (NACE) consisting of target lesion revascularization (TLR, primary endpoint of all-comers observational studies) all-cause death, myocardial infarction (MI), stent thrombosis (ST), and bleeding events. A logistic regression was utilized to determine predictors why ticagrelor was used in stable coronary artery disease (CAD) patients instead of the guideline-recommended clopidogrel. Results For stable CAD, the composite endpoint of clinical, bleeding, and stent thrombosis, i.e., NACE, between the clopidogrel and ticagrelor treatment groups was not different (5.4% vs. 5.1%, p = 0.745). Likewise, in the acute coronary syndrome (ACS) cohort, the NACE rates were not different between both DAPT strategies (9.2% vs. 9.3%, p = 0.927). There were also no differences in the accumulated rates for TLR, myocardial infarction ([MI], mortality, bleeding events, and stent thrombosis in elective and ACS patients. The main predictors for ticagrelor use in stable CAD patients were age < 65 years, smaller vessels, treatment of ostial and calcified lesions, and in-stent restenosis. Conclusion Within the framework of a post hoc analysis based on a real-world, large cohort study, there were no differences in the combined endpoint of major adverse cardiac events (MACE), bleeding and thrombotic events for clopidogrel and ticagrelor in stable CAD or ACS patients. Despite the recommendation for clopidogrel by the European Society of Cardiology (ESC), real-world ticagrelor use was observed in subgroups of stable CAD patients that ought to be explored in future trials.
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Affiliation(s)
- Florian Krackhardt
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, D-13353, Berlin, Germany.
| | - Matthias Waliszewski
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, D-13353, Berlin, Germany
- Medical Scientific Affairs, B.Braun Melsungen AG, Berlin, Germany
| | - Viktor Kočka
- University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Petr Toušek
- University Hospital Královské Vinohrady, Prague, Czech Republic
| | | | | | - Fernando Lozano
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | | | - Josepa Mauri
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Tae Hoon Ahn
- Gachon University Gil Medical Center, Incheon, South Korea
| | | | - Denny Herberger
- Medical Scientific Affairs, B.Braun Melsungen AG, Berlin, Germany
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Godino C, Pivato CA, Rubino C, Russi A, Cera M, Margonato A. Antithrombotic Therapy After Percutaneous Coronary Intervention in Atrial Fibrillation. Am J Cardiol 2020; 129:122-124. [PMID: 32540165 DOI: 10.1016/j.amjcard.2020.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/08/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Cosmo Godino
- San Raffaele Scientific Institute, Milan, Italy.
| | | | | | - Anita Russi
- San Raffaele Scientific Institute, Milan, Italy
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Gajanana D, Rogers T, Weintraub WS, Kolm P, Iantorno M, Khalid N, Chen Y, Shlofmitz E, Khan JM, Musallam A, Ben-Dor I, Satler LF, Zhang C, Torguson R, Waksman R. Ischemic Versus Bleeding Outcomes After Percutaneous Coronary Interventions in Patients With High Bleeding Risk. Am J Cardiol 2020; 125:1631-1637. [PMID: 32273057 DOI: 10.1016/j.amjcard.2020.02.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 01/13/2023]
Abstract
Patients undergoing percutaneous coronary intervention (PCI) often have high-bleeding-risk (HBR) factors. Dual antiplatelet therapy (DAPT) further increases this risk of bleeding. We sought to compare clinical outcomes according to presence or absence of HBR factors in patients with elevated ischemic risk (DAPT score ≥ 2) undergoing PCI. We evaluated all patients undergoing PCI at MedStar Washington Hospital Center (January 2009 to July 2018) with DAPT score ≥2, which is associated with elevated risk of ischemic events. Patients were categorized as HBR group (HBR score ≥1) or low-bleeding-risk (LBR) group (HBR score = 0). Outcomes included major adverse cardiac events such as target vessel revascularization, stent thrombosis, death, and bleeding events at 30 days, 6 months, 1 year, and 2 years. The final cohort consisted of 7,499 patients: 3,949 patients had LBR features, and 3,550 patients had HBR features. The 2 groups were different at baseline, with HBR patients being older and having a higher prevalence of congestive heart failure and renal dysfunction than the LBR group. The mean DAPT score was 2.96±1.1 for the LBR group and 3.7±1.4 for the HBR group (p <0.001). During follow-up at 30 days, 6 months, and 1 and 2 years, the rates of target vessel revascularization and stent thrombosis were not significantly different between the 2 groups. Bleeding events and all-cause mortality were significantly more frequent in the HBR group than in the LBR group. In conclusion, patients undergoing PCI often have pre-existing risk factors that predispose them to ischemic and bleeding complications. Prolonged duration of DAPT to mitigate ischemic events could lead to a disproportionate increase in bleeding events, especially in HBR patients.
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Affiliation(s)
- Deepakraj Gajanana
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC; Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - William S Weintraub
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Paul Kolm
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Micaela Iantorno
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Nauman Khalid
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Yuefeng Chen
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Evan Shlofmitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Jaffar M Khan
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Anees Musallam
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
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Gencer B, Li XS, Gurmu Y, Bonaca MP, Morrow DA, Cohen M, Bhatt DL, Steg PG, Storey RF, Johanson P, Wang Z, Hazen SL, Sabatine MS. Gut Microbiota-Dependent Trimethylamine N-oxide and Cardiovascular Outcomes in Patients With Prior Myocardial Infarction: A Nested Case Control Study From the PEGASUS-TIMI 54 Trial. J Am Heart Assoc 2020; 9:e015331. [PMID: 32366163 PMCID: PMC7660879 DOI: 10.1161/jaha.119.015331] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/10/2020] [Indexed: 12/28/2022]
Abstract
Background Trimethylamine N-oxide (TMAO) may have prothrombotic properties. We examined the association of TMAO quartiles with major adverse cardiovascular events (MACE) and the effect of TMAO on the efficacy of ticagrelor. Methods and Results PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin - Thrombolysis in Myocardial Infarction 54) randomized patients with prior myocardial infarction to ticagrelor or placebo (median follow-up 33 months). Baseline plasma concentrations of TMAO were measured in a nested case-control study of 597 cases with cardiovascular death, myocardial infarction, or stroke (MACE) and 1206 controls matched for age, sex, and estimated glomerular filtration rate [eGFR]. Odds ratios (OR) were used for the association between TMAO quartiles and MACE, adjusting for baseline clinical characteristics (age, sex, eGFR, region, body mass index, hypertension, hypercholesterolemia, diabetes mellitus, smoking, peripheral artery disease, index event, aspirin dosage and treatment arm), and cardiovascular biomarkers (hs-TnT [high-sensitivity troponin T], hs-CRP [high-sensitivity C-reactive protein], NT-proBNP [N-terminal-pro-B-type natriuretic peptide]). Higher TMAO quartiles were associated with risk of MACE (OR for quartile 4 versus quartile 1, 1.43, 95% CI, 1.06-1.93, P trend=0.015). The association was driven by cardiovascular death (OR 2.25, 95% CI, 1.28-3.96, P trend=0.003) and stroke (OR 2.68, 95% CI, 1.39-5.17, P trend<0.001). After adjustment for clinical factors, the association persisted for cardiovascular death (ORadj 1.89, 95% CI, 1.03-3.45, P trend=0.027) and stroke (ORadj 2.01, 95% CI, 1.01-4.01, P trend=0.022), but was slightly attenuated after adjustment for cardiovascular biomarkers (cardiovascular death: ORadj 1.74, 95% CI, 0.88-3.45, P trend=0.079; and stroke: ORadj 1.82, 95% CI, 0.88-3.78, P trend=0.056). The reduction in MACE with ticagrelor was consistent across TMAO quartiles (P interaction=0.92). Conclusions Among patients with prior myocardial infarction, higher TMAO levels were associated with cardiovascular death and stroke but not with recurrent myocardial infarction. The efficacy of ticagrelor was consistent regardless of TMAO levels. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: PEGASUS-TIMI 54, NCT01225562.
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Affiliation(s)
- Baris Gencer
- TIMI Study GroupDivision of Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Xinmin S. Li
- Department of Cardiovascular and Metabolic SciencesLerner Research InstituteCleveland ClinicClevelandOH
| | - Yared Gurmu
- TIMI Study GroupDivision of Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Marc P. Bonaca
- CPC Clinical ResearchDivision of Cardiovascular MedicineUniversity of ColoradoDenverCO
| | - David A. Morrow
- TIMI Study GroupDivision of Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | - Marc Cohen
- Newark Beth Israel Medical CenterRutgers‐New Jersey Medical SchoolNewarkNJ
| | - Deepak L. Bhatt
- TIMI Study GroupDivision of Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
| | | | - Robert F. Storey
- Cardiovascular Research UnitDepartment of Infection, Immunity and Cardiovascular DiseaseUniversity of SheffieldUnited Kingdom
| | | | - Zeneng Wang
- Department of Cardiovascular and Metabolic SciencesLerner Research InstituteCleveland ClinicClevelandOH
| | - Stanley L. Hazen
- Department of Cardiovascular and Metabolic SciencesLerner Research InstituteCleveland ClinicClevelandOH
- Department of Cardiovascular Medicine, Heart and Vascular InstituteCleveland ClinicClevelandOH
| | - Marc S. Sabatine
- TIMI Study GroupDivision of Cardiovascular MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMA
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Franchi F, Rollini F, Faz G, Rivas JR, Rivas A, Agarwal M, Briceno M, Wali M, Nawaz A, Silva G, Shaikh Z, Maaliki N, Fahmi K, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Baber U, Mehran R, Jennings LK, Bass TA, Angiolillo DJ. Pharmacodynamic Effects of Vorapaxar in Prior Myocardial Infarction Patients Treated With Potent Oral P2Y 12 Receptor Inhibitors With and Without Aspirin: Results of the VORA-PRATIC Study. J Am Heart Assoc 2020; 9:e015865. [PMID: 32306797 PMCID: PMC7428520 DOI: 10.1161/jaha.120.015865] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
Background Vorapaxar as an adjunct to dual antiplatelet therapy (DAPT) reduces thrombotic events in patients with prior myocardial infarction at the expense of increased bleeding. Withdrawal of aspirin has emerged as a bleeding reduction strategy. The pharmacodynamic effects of vorapaxar with potent P2Y12 inhibitors as well as the impact of dropping aspirin is unexplored and represented the aim of the VORA-PRATIC (Vorapaxar Therapy in Patients With Prior Myocardial Infarction Treated With Newer Generation P2Y12 Receptor Inhibitors Prasugrel and Ticagrelor) study. Methods and Results Post-myocardial infarction patients (n=130) on standard DAPT (aspirin+prasugrel or ticagrelor) were randomized to 1 of 3 arms: (1) triple therapy: aspirin+prasugrel/ticagrelor+vorapaxar; (2) dual therapy (drop aspirin): prasugrel/ticagrelor+vorapaxar; (3) DAPT: aspirin+prasugrel/ticagrelor. Pharmacodynamic assessments were performed at 3 time points (baseline and 7 and 30 days). Vorapaxar reduced CAT (collagen-ADP-TRAP)-induced platelet aggregation, a marker of platelet-mediated global thrombogenicity (triple therapy versus DAPT at 30 days: mean difference=-27; 95% CI,-35 to -19; P<0.001; primary end point). This effect was attenuated but still significant in the absence of aspirin (dual therapy versus DAPT at 30 days: mean difference=-15; 95% CI,-23 to -7; P<0.001; between-group comparisons, P<0.05). Vorapaxar abolished TRAP-induced aggregation (P<0.001), without affecting thrombin generation and clot strength. There were no differences in markers of P2Y12 reactivity. Markers sensitive to aspirin-induced effects increased (P<0.001) in the dual-therapy arm. Conclusions In post-myocardial infarction patients treated with potent P2Y12 inhibitors, vorapaxar reduces platelet-driven global thrombogenicity, an effect that persisted, albeit attenuated, in the absence of aspirin and without affecting markers of P2Y12 reactivity or clot kinetics. The clinical implications of these PD observations warrant future investigation. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02545933.
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Affiliation(s)
| | | | - Gabriel Faz
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Andrea Rivas
- University of Florida College of Medicine–JacksonvilleFL
| | - Malhar Agarwal
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Mustafa Wali
- University of Florida College of Medicine–JacksonvilleFL
| | - Ahmed Nawaz
- University of Florida College of Medicine–JacksonvilleFL
| | - Gabriel Silva
- University of Florida College of Medicine–JacksonvilleFL
| | - Zubair Shaikh
- University of Florida College of Medicine–JacksonvilleFL
| | - Naji Maaliki
- University of Florida College of Medicine–JacksonvilleFL
| | - Kerolos Fahmi
- University of Florida College of Medicine–JacksonvilleFL
| | - Latonya Been
- University of Florida College of Medicine–JacksonvilleFL
| | | | | | - Daniel Soffer
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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D'Ascenzo F, Barbero U, Abdirashid M, Trabattoni D, Boccuzzi G, Ryan N, Quadri G, Capodanno D, Venuti G, Muscoli S, Tomassini F, Autelli M, Montabone A, Wojakowski W, Rognoni A, Gallo D, Parma R, De Luca L, Figini F, Mitomo S, Montefusco A, Mattesini A, Wańha W, Protasiewicz M, Smolka G, Huczek Z, Rolfo C, Cortese B, Chieffo A, Kuliczowki W, Nuñez-Gil I, Morbiducci U, Ugo F, Marengo G, Iannaccone M, Cerrato E, Mario CD, Moretti C, D'Amico M, Varbella F, Lüscher TF, Sheiban I, Escaned J, Romeo F, Rinaldi M, De Ferrari GM, Helft G. Incidence of Adverse Events at 3 Months Versus at 12 Months After Dual Antiplatelet Therapy Cessation in Patients Treated With Thin Stents With Unprotected Left Main or Coronary Bifurcations. Am J Cardiol 2020; 125:491-499. [PMID: 31889527 DOI: 10.1016/j.amjcard.2019.10.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 11/29/2022]
Abstract
Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with thin stents (<100 microns) in unprotected left main (ULM) or coronary bifurcation remain undefined. All consecutive patients presenting with a critical lesion of an ULM or involving a main coronary bifurcation who were treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]) was the primary endpoint, whereas target vessel revascularization (TVR) was the secondary endpoint, with particular attention to type and occurrence of ST and occurrence of ST, CV death, and MI during DAPT or after DAPT discontinuation. All analyses were performed according to length of DAPT dividing the patients in 3 groups: Short DAPT (3-months), intermediate DAPT (3 to 12 months), and long DAPT (12-months). A total of 117 patients were discharged with an indication for DAPT ≤3 months (median 1: 1 to 2.5), 200 for DAPT between 3 and 12 months (median 8: 7 to 10), and 1,958 with 12 months DAPT. After 12.8 months (8 to 20), MACE was significantly higher in the 3-month group compared with 3 to 12 and 12-month groups (9.4% vs 4.0% vs 7.2%, p ≤0.001), mainly driven by MI (4.4% vs 1.5% vs 3%, p ≤0.001) and overall ST (4.3% vs 1.5% vs 1.8%, p ≤0.001). Independent predictors of MACE were low GFR and a 2 stent strategy. Independent predictors of ST were DAPT duration <3 months and the use of a 2-stent strategy. In conclusion, even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy; Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan; Division of Cardioloy, Universityspirtal of Zürich, Zürich, Switzerland
| | - Umberto Barbero
- Ospedale Civile SS. Annunziata, Savigliano, Italiy, Via Ospedali, 9, 12038
| | - Mohamed Abdirashid
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy.
| | - Daniela Trabattoni
- Department of Cardiovascular Sciences, IRCCS Centro Cardiologico Monzino, Milan, Italy; University of Milan, Milan, Italy
| | | | - Nicola Ryan
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Giorgio Quadri
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Giuseppe Venuti
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele," Catania, Italy
| | - Saverio Muscoli
- San Raffaele Scientific Institute, Milan, Italy; Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Francesco Tomassini
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Michele Autelli
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Andrea Montabone
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | | | - Andrea Rognoni
- Coronary Care Unit and Catheterization laboratory, A.O.U. Maggiore della Carità, Novara, Italy
| | - Diego Gallo
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, and Royal Brompton and Harefield Hospital Trust and Imperial College, London, United Kingdom
| | | | - Leonardo De Luca
- Division of Cardiology, S. Giovanni Evangelista Hospital, Tivoli, Italy
| | | | - Satoru Mitomo
- San Raffaele Scientific Institute, Milan, Italy; Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Antonio Montefusco
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Alessio Mattesini
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Wojciech Wańha
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Marcin Protasiewicz
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Grzegorz Smolka
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Cristina Rolfo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Bernardo Cortese
- Interventional Cardiology, ASST Fatebenefratelli-Sacco, Milano, Italy
| | | | - Wiktor Kuliczowki
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Ivan Nuñez-Gil
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Umberto Morbiducci
- Polito(BIO)Med Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, and Royal Brompton and Harefield Hospital Trust and Imperial College, London, United Kingdom
| | - Fabrizio Ugo
- Dipartimento di Cardiologia, Ospedale San Giovanni Bosco, Italy
| | - Giorgio Marengo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Mario Iannaccone
- Ospedale Civile SS. Annunziata, Savigliano, Italiy, Via Ospedali, 9, 12038
| | - Enrico Cerrato
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Claudio Moretti
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Maurizio D'Amico
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Ferdinando Varbella
- Department of Cardiology, Infermi Hospital, Rivoli, Italy; Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Thomas F Lüscher
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | | | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Francesco Romeo
- Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | - Mauro Rinaldi
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Turin, Italy
| | - Gerard Helft
- Pierre and Marie Curie University, Paris, France
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Verdoia M, Rolla R, Negro F, Tonon F, Pergolini P, Nardin M, Marcolongo M, De Luca G. Homocysteine levels and platelet reactivity in coronary artery disease patients treated with ticagrelor. Nutr Metab Cardiovasc Dis 2020; 30:292-299. [PMID: 31780401 DOI: 10.1016/j.numecd.2019.09.018] [Citation(s) in RCA: 8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/19/2019] [Accepted: 09/17/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Recurrent atherothrombotic events have been reported in certain higher risk subsets of patients even with ticagrelor, a potent first-line antiplatelet agent for the management of patients with acute coronary syndrome (ACS). Hyperhomocysteinemia is a known determinant of platelet function abnormalities. Therefore, the aim of our study was to evaluate the impact of homocysteine (Hcy) levels on platelet reactivity in patients receiving Ticagrelor. METHODS AND RESULTS Patients with ACS undergoing percutaneous coronary revascularization and on dual antiplatelet therapy with ASA + Ticagrelor (90mg/twice a day) were scheduled for platelet function assessment 30-90 days post-discharge. Aggregation tests were performed by Multiple Electrode Aggregometry (MEA). Suboptimal platelet inhibition HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). We included 432 patients, divided according to Hcy tertiles. Higher Hcy levels were associated with age, renal failure, creatinine levels and use diuretics (p < 0.001). Patients with higher Hcy levels displayed a higher platelet reactivity at COL test (p = 0.002), and ADP test (p = 0.04), with a linear relationship between Hcy and platelet aggregation after stimulation with collagen (r = 0.202, p < 0.001), thrombin receptor peptide (r = 0.104, p = 0.05) and ADP (r = 0.145, p = 0.006). However, Hcy levels did not significantly affect the rate of HRPR with Ticagrelor (9.9% vs 13.7% vs 10.7%, p = 0.89; adjusted OR [95% CI] = [0.616-1.51], p = 0.99). CONCLUSIONS Among patients with ACS, despite the elevated platelet reactivity associated to hyperhomocysteinemia, DAPT with ticagrelor could overcome such phenomenon, achieving an adequate platelet inhibition in the majority of the patients.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Roberta Rolla
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Federica Negro
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Francesco Tonon
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Patrizia Pergolini
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Matteo Nardin
- Department of Internal Medicine, ASST Spedali Civili, Brescia, Italy
| | - Marco Marcolongo
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, Italy
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Yang H, Zhang F, Yang J, Zheng M, Cao R, Dai Y, Li C, Yao K, Qian J, Ge J. Prospective multicentre open-label randomised controlled trial of 3-month versus 12-month dual antiplatelet therapy after implantation of the new generation biodegradable polymer sirolimus TARGET-eluting coronary stent: protocol of the TARGET DAPT trial. BMJ Open 2019; 9:e033774. [PMID: 31852711 PMCID: PMC6937074 DOI: 10.1136/bmjopen-2019-033774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) with aspirin and thienopyridine is required after placement of coronary stents to prevent thrombotic complications. However, current recommendation for duration of DAPT remains controversial. Firehawk is a biodegradable polymer applied to recessed abluminal grooves, sirolimus target-eluting stent associated with early excellent healing response and almost complete strut coverage, as well as possibly reduced myocardial ischaemic events. But the optimal DAPT duration for such a new generation stent is less known. Therefore, the present trial seeks to evaluate the safety and efficacy of 3-month versus 12-month DAPT in broad patients receiving Firehawk stents. METHODS AND ANALYSIS The TARGET DAPT study is designed to access the benefits and risks of short-term (3 months) versus long-term (12 months) DAPT in preventing stent thrombosis or major adverse cardiovascular and cerebrovascular events in subjects undergoing percutaneous coronary intervention for the treatment of coronary artery obstructive lesions. The TARGET DAPT trial is a large, prospective, multicentre, randomised (1:1) non-inferiority clinical trial that will enrol 2446 subjects treated with Firehawk stents. The primary endpoint is net adverse clinical and cerebral events, a composite of all-cause death, myocardial infarction, cerebral vascular accident and major bleeding (BARC 2,3 or 5) at 18 months clinical follow-up postindex procedure. ETHICS AND DISSEMINATION Ethics approval was obtained from the Ethics Committee of Zhongshan Hospital, Shanghai. The reference number is B2018-146R. Study findings will be made available to interested participants. Study results will be submitted for publication in a peer-reviewed journal. Also the protocol will be submitted and approved by the institutional Ethics Committee at each participating clinical centre. TRIAL REGISTRATION NCT03008083.
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Affiliation(s)
- Hongbo Yang
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Feng Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Ji'e Yang
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Ming Zheng
- Shanghai MicroPort Medical Group Co, Ltd, Shanghai, China
| | - Ruifen Cao
- Shanghai MicroPort Medical Group Co, Ltd, Shanghai, China
| | - Yuxiang Dai
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Kang Yao
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University; Shanghai Institute of Cardiovascular Diseases, Shanghai, China
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