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Jebrin R, El Nekidy WS, Abidi E, John TLS, Kesav P, Hussain SI, Abdelsalam M, Khaled L, Raj D, John S. Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East. Clin Neurol Neurosurg 2024; 239:108167. [PMID: 38402103 DOI: 10.1016/j.clineuro.2024.108167] [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: 10/21/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population. METHODS We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019. RESULTS During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79-12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors. CONCLUSION This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.
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Affiliation(s)
- Rita Jebrin
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Emna Abidi
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Praveen Kesav
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Syed I Hussain
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Luna Khaled
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Divya Raj
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Seby John
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States.
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Suyama K, Nakahara I, Matsumoto S, Morioka J, Tanabe J, Hasebe A, Watanabe S. Efficacy and Safety of Dual Antiplatelet Therapy with the Routine Use of Prasugrel for Flow Diversion of Cerebral Unruptured Aneurysms. Clin Neuroradiol 2024; 34:201-208. [PMID: 37847296 PMCID: PMC10881594 DOI: 10.1007/s00062-023-01355-2] [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: 06/28/2023] [Accepted: 09/26/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE Prasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen. METHODS This retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded. RESULTS During the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%. CONCLUSIONS Dual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications.
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Affiliation(s)
- Kenichiro Suyama
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan.
| | - Ichiro Nakahara
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Shoji Matsumoto
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Jun Morioka
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Jun Tanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Akiko Hasebe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Sadayoshi Watanabe
- Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
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Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Domei T, Suwa S, Ogita M, Isawa T, Takenaka H, Yamamoto T, Ishikawa T, Hisauchi I, Wakabayashi K, Onishi Y, Hibi K, Kawai K, Yoshida R, Suzuki H, Nakazawa G, Kusuyama T, Morishima I, Ono K, Kimura T. An Aspirin-Free Versus Dual Antiplatelet Strategy for Coronary Stenting: STOPDAPT-3 Randomized Trial. Circulation 2024; 149:585-600. [PMID: 37994553 DOI: 10.1161/circulationaha.123.066720] [Citation(s) in RCA: 2] [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: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Bleeding rates on dual antiplatelet therapy (DAPT) within 1 month after percutaneous coronary intervention (PCI) remain high in clinical practice, particularly in patients with acute coronary syndrome or high bleeding risk. Aspirin-free strategy might result in lower bleeding early after PCI without increasing cardiovascular events, but its efficacy and safety have not yet been proven in randomized trials. METHODS We randomly assigned 6002 patients with acute coronary syndrome or high bleeding risk just before PCI either to prasugrel (3.75 mg/day) monotherapy or to DAPT with aspirin (81-100 mg/day) and prasugrel (3.75 mg/day) after loading of 20 mg of prasugrel in both groups. The coprimary end points were major bleeding (Bleeding Academic Research Consortium 3 or 5) for superiority and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke) for noninferiority with a relative 50% margin. RESULTS The full analysis set population consisted of 5966 patients (no-aspirin group, 2984 patients; DAPT group, 2982 patients; age, 71.6±11.7 years; men, 76.6%; acute coronary syndrome, 75.0%). Within 7 days before randomization, aspirin alone, aspirin with P2Y12 inhibitor, oral anticoagulants, and intravenous heparin infusion were given in 21.3%, 6.4%, 8.9%, and 24.5%, respectively. Adherence to the protocol-specified antiplatelet therapy was 88% in both groups at 1 month. At 1 month, the no-aspirin group was not superior to the DAPT group for the coprimary bleeding end point (4.47% and 4.71%; hazard ratio, 0.95 [95% CI, 0.75-1.20]; Psuperiority=0.66). The no-aspirin group was noninferior to the DAPT group for the coprimary cardiovascular end point (4.12% and 3.69%; hazard ratio, 1.12 [95% CI, 0.87-1.45]; Pnoninferiority=0.01). There was no difference in net adverse clinical outcomes and each component of coprimary cardiovascular end point. There was an excess of any unplanned coronary revascularization (1.05% and 0.57%; hazard ratio, 1.83 [95%CI, 1.01-3.30]) and subacute definite or probable stent thrombosis (0.58% and 0.17%; hazard ratio, 3.40 [95% CI, 1.26-9.23]) in the no-aspirin group compared with the DAPT group. CONCLUSIONS The aspirin-free strategy using low-dose prasugrel compared with the DAPT strategy failed to attest superiority for major bleeding within 1 month after PCI but was noninferior for cardiovascular events within 1 month after PCI. However, the aspirin-free strategy was associated with a signal suggesting an excess of coronary events. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04609111.
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Affiliation(s)
- Masahiro Natsuaki
- Department of Cardiovascular Medicine, Saga University, Japan (M.N.)
| | - Hirotoshi Watanabe
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (T.M.)
| | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan (K.Y., K.A., T.D.)
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan (S.S., M.O.)
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan (S.S., M.O.)
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Japan (T. Isawa)
| | - Hiroyuki Takenaka
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Takashi Yamamoto
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
| | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan (T. Ishikawa, I.H.)
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan (T. Ishikawa, I.H.)
| | - Kohei Wakabayashi
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan (K.W.)
| | - Yuko Onishi
- Department of Cardiology, Hiratsuka Kyosai Hospital, Japan (Y. Onishi)
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Japan (K.H.)
| | - Kazuya Kawai
- Division of Cardiology, Chikamori Hospital, Kochi, Japan (K.K.)
| | - Ruka Yoshida
- Division of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan (R.Y.)
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan (H.S.)
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osakasayama, Japan (G.N.)
| | - Takanori Kusuyama
- Division of Cardiology, Tsukazaki Hospital, Himeji, Japan (T. Kusuvama)
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, Japan (I.M.)
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (Y. Obayashi, R.N., K.O.)
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan (H.W., H.T., T.Y., T.K.)
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Fujii T, Amano K, Kasai S, Kawamura Y, Yoshimachi F, Ikari Y. Impact of renal function on adverse bleeding events associated with dual antiplatelet therapy in patients with acute coronary syndrome. Cardiovasc Interv Ther 2024; 39:28-33. [PMID: 37782383 DOI: 10.1007/s12928-023-00963-6] [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: 07/28/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023]
Abstract
It is believed, but not well established, that renal dysfunction increases the risk of adverse bleeding events associated with dual antiplatelet therapy (DAPT), especially in patients with acute coronary syndrome (ACS). The aim of this study is to estimate the impact of renal function on adverse bleeding events associated with DAPT in patients with ACS. A total of 1,264 ACS patients who received DAPT, clopidogrel (n = 530) or prasugrel (n = 734) in addition to aspirin, were assessed in a multicenter observational study. The relationship between renal function and bleeding event, defined as BARC 3 or 5, was determined using a marginal effect from the logit model and Royston-Parmar model. During an average 313.1 days of the observation period, defined as the duration of DAPT after admission until the implementation of a change in the regimen, bleeding events were observed in 7.4% of patients (n = 94). The estimated curves demonstrated that the probability of bleeding was positive correlated with renal dysfunction (6.0 to 8.6), regardless of the DAPT regimen used. This probability was consistently higher in clopidogrel (7.4 to 10.5) than in prasugrel (4.8 to 0.7). This trend was also shown in maintenance hemodialysis patients (6.7 vs. 10.3). Estimated cumulative incidences among individual stages of renal function were drawn. In conclusion, bleeding events increased with worsening renal function, and prasugrel is safer than clopidogrel as a component of DAPT throughout all levels of renal function, including hemodialysis patients after ACS.
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Affiliation(s)
- Toshiharu Fujii
- Department of Cardiovascular Medicine, Tokai University School of Medicine, Isehara, Japan.
- Department of Cardiovascular Medicine, Tokai University Hachioji Hospital, Hachioji, Japan.
- Department of Cardiovascular Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Japan.
| | - Kazushige Amano
- Department of Cardiovascular Medicine, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Satoshi Kasai
- Department of Cardiovascular Medicine, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Yota Kawamura
- Department of Cardiovascular Medicine, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Fuminobu Yoshimachi
- Department of Cardiovascular Medicine, Tokai University Hachioji Hospital, Hachioji, Japan
| | - Yuji Ikari
- Department of Cardiovascular Medicine, Tokai University School of Medicine, Isehara, Japan
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Liu C, Ma L. Comparison efficacy and safety of different antiplatelet or anticoagulation drugs in chronic coronary syndromes patients: A Bayesian network meta-analysis. Medicine (Baltimore) 2023; 102:e36429. [PMID: 38050293 PMCID: PMC10695535 DOI: 10.1097/md.0000000000036429] [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: 09/10/2023] [Accepted: 11/10/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND A systematic review and network meta-analysis (NMA) were conducted to explore the efficacy and safety of different antiplatelet or anticoagulation drugs in chronic coronary syndromes patients. METHODS Electronic databases (Pubmed, Embase and Cochrane databases) were systematically searched to identify randomized controlled trials evaluating different antiplatelet or anticoagulation drugs (aspirin, aspirin + clopidogrel, aspirin + clopidogrel + cilostazol, clopidogrel/prasugrel + aspirin, aspirin + rivaoxaban 2.5 mg, aspirin + ticagrelor 60 mg, aspirin + ticagrelor 90 mg, clopidogrel or rivroxaban 5 mg) versus placebo for treatment chronic coronary syndromes patients. Outcomes included major adverse cardiovascular events, all cause death, major bleeding and myocardial infarction. A random-effect Bayesian NMA was conducted for outcomes of interest, and results were presented as odds ratios (ORs) and 95% credible intervals. The NMA was performed using R Software with a GeMTC package. A Bayesian NMA was performed and relative ranking of agents was assessed using surface under the cumulative ranking probabilities. RESULTS Ten randomized controlled trials met criteria for inclusion and finally included in this NMA. In head-to-head comparison, no significant difference was observed between all antithrombotic treatment strategies with respect to primary endpoint of major adverse cardiovascular events. In head-to-head comparison, no significant difference was observed between all antithrombotic treatment strategies with respect to all cause death. Clopidogrel/prasugrel + aspirin (OR = 3.8, 95% credible intervals [CrI]: 1.3-12.0, P < .05) and aspirin + rivaroxaban 2.5 mg (OR = 3.1, 95%CrI: 1.1-9.5, P < .05) was associated with an increase of the major bleeding. Compared with aspirin alone, aspirin + clopidogrel (OR = 0.42, 95%CrI: 0.22-0.76, P < .05) and aspirin + ticagrelor 90 mg (OR = 0.42, 95%CrI: 0.17-0.95, P < .05) was associated with a decrease of the myocardial infarction. CONCLUSIONS Myocardial infarction was significantly lower when adding clopidogrel or ticagrelor 90 mg to aspirin than those in the aspirin alone group. However, clopidogrel/prasugrel and rivaroxaban 2.5 mg was associated with an increase of the major bleeding than aspirin alone.
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Affiliation(s)
- Chang Liu
- Department of Cardiology, Chongqing Traditional Medicine Hospital, Chongqing 400021, China
| | - Lei Ma
- Department of Internal Medicine, Chongqing Fire and Rescue Hospital, Chongqing, China
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De Luca L, Gragnano F, Calabrò P, Huber K. Balancing Benefits and Risks of Oral Antiplatelet Strategies in patients With Coronary Artery Diseases: An Evolving Issue. Curr Probl Cardiol 2023; 48:102025. [PMID: 37553063 DOI: 10.1016/j.cpcardiol.2023.102025] [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] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Identifying the most appropriate antiplatelet therapy for each patient to prevent ischemic events while minimizing the risk of bleeding is an integral part of the short- and long-term management of patients with coronary artery disease (CAD). This review aims to summarize the available evidence on the contemporary use of P2Y12 inhibitors in CAD patients, focusing on strategies aimed at providing adequate ischemic protection while preventing bleeding risk through dual antiplatelet therapy (DAPT) modulation. Randomized trials and observational studies have been reviewed to determine the most appropriate antiplatelet treatment for CAD patients with different risk profiles. Both ischemic and bleeding events have a significant prognostic impact and should be carefully considered in clinical decision-making. Current guidelines recommend the use of third-generation PY2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel, as a part of DAPT, in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Newer P2Y12 inhibitors have a more rapid onset of action and less interindividual variability in platelet inhibition than clopidogrel but are associated with an increased risk of bleeding that may limit their benefit. Importantly, the anti-ischemic benefit of ticagrelor and prasugrel is mainly observed in the first weeks after ACS, whereas clopidogrel seems to provide the best balance between ischemic protection and bleeding as long-term maintenance therapy. These concepts support DAPT modulation after the acute phase, by de-escalating from full-dose to low-dose newer P2Y12 inhibitors, by switching to clopidogrel, or by early withdrawing aspirin to maximize both the efficacy and safety of antiplatelet therapy in patients with CAD.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, and Sigmund Freud University, Medical Faculty, Vienna, Austria
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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Komócsi A, Merkely B, Hadamitzky M, Massberg S, Rizas KD, Hein-Rothweiler R, Gross L, Trenk D, Sibbing D, Aradi D. Impact of body mass on P2Y12-inhibitor de-escalation in acute coronary syndromes-a substudy of the TROPICAL-ACS trial. Eur Heart J Cardiovasc Pharmacother 2023; 9:608-616. [PMID: 37015874 PMCID: PMC10627813 DOI: 10.1093/ehjcvp/pvad027] [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] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/10/2023] [Accepted: 04/03/2023] [Indexed: 04/06/2023]
Abstract
AIMS Clinical guidelines recommend de-escalation antiplatelet strategies to reduce bleeding risk in acute coronary syndrome (ACS) patients, albeit with a weak recommendation. This substudy of the TROPICAL-ACS trial aimed to determine the impact of body mass on the efficacy of a platelet function testing-guided de-escalation regimen in ACS patients after percutaneous coronary intervention. METHODS AND RESULTS Patients were randomized to prasugrel (control group) or a platelet function testing-guided regimen with clopidogrel or prasugrel defined after 1-week clopidogrel. The primary endpoint was the net clinical benefit [cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium (BARC) 2-5 bleeding] for 12 months. Overweight was defined as a body mass index >25 kg/m2.Patients without overweight showed a significant net clinical benefit from the de-escalation strategy, while in overweight cases de-escalation was comparable to prasugrel treatment [hazard ratio (HR): 0.52; 95% confidence interval (CI): 0.31-0.88; P = 0.013 and HR: 0.95; 95% CI: 0.69-1.31, P = 0.717, P-non-inferiority = 0.03, respectively, P-interaction = 0.053]. The benefit of de-escalation in terms of the risk of bleeding or of the ischaemic events did not reach statistical significance. Bleeding events with de-escalation were less frequent in non-overweight patients but comparable in overweight patients (HR: 0.55; 95% CI: 0.30-1.03; P = 0.057 and HR: 0.95; 95% CI: 0.64-1.41, respectively, P-interaction = 0.147). Non-overweight patients had lower ischaemic event rates with de-escalation, while overweight cases had slightly less (HR: 0.47; 95% CI: 0.18-1.25; P = 0.128 and HR: 0.89; 95% CI: 0.53-1.50, respectively, P-interaction = 0.261). CONCLUSION The strategy of guided dual antiplatelet therapy de-escalation was associated with a significant net clinical benefit in non-overweight patients, while the two strategies were equivalent in overweight patients.
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Affiliation(s)
- András Komócsi
- Heart Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Lisa Gross
- Ludwig-Maximilians University, Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology–Clinical Pharmacology, Medical Center–University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | | | - Dániel Aradi
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
- Balatonfured State Cardiology Hospital, Balatonfured, Hungary
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9
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Jacobsen MR, Jabbari R, Engstrøm T, Grove EL, Glinge C, Pedersen F, Holmvang L, Køber L, Torp-Pedersen C, Maeng M, Veien K, Freeman P, Charlot MG, Kelbæk H, Sørensen R. Bleeding risk and P2Y12 inhibitors in all-comer patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: a single-centre cohort study. Eur Heart J Cardiovasc Pharmacother 2023; 9:617-626. [PMID: 37403404 DOI: 10.1093/ehjcvp/pvad048] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/26/2023] [Accepted: 07/03/2023] [Indexed: 07/06/2023]
Abstract
AIMS To characterize and follow patients with ST-segment elevation myocardial infarction (STEMI) at high bleeding risk (HBR) according to the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score, and to examine the use of P2Y12 inhibitors and the subsequent risk of major adverse cardiovascular events (MACE) and bleeding. METHODS AND RESULTS This single-centre cohort study included 6179 consecutive STEMI patients who underwent percutaneous coronary intervention (PCI) at Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Individual linkage to nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Of the 5532 (89.5%) patients with available PRECISE-DAPT scores, 33.0% were at HBR and more often elderly and female with more comorbidities than non-HBR patients. One-year cumulative incidence rates per 100 person-years were 8.7 and 2.1 for major bleeding and 36.8 and 8.3 for MACE in HBR and non-HBR patients, respectively. Among the 4749 (85.8%) patients who survived and collected a P2Y12 inhibitor ≤7 days from discharge, 68.2% of HBR patients were treated with ticagrelor or prasugrel and 31.8% with clopidogrel, while 18.2% non-HBR patients were treated with clopidogrel. Adherence was high for all (>75% days coverage). The risk of MACE was lower in ticagrelor- and prasugrel-treated patients than in clopidogrel-treated patients without differences in major bleeding. CONCLUSION One-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and were more often treated with potent P2Y12 inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR.
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Affiliation(s)
- Mia Ravn Jacobsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Reza Jabbari
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Charlotte Glinge
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Karsten Veien
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Phillip Freeman
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Gitz Charlot
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Henning Kelbæk
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
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10
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Girotra S, Stebbins A, Wruck L, Marquis‐Gravel G, Gupta K, Farrehi P, Benziger CP, Effron MB, Whittle J, Muñoz D, Kripalani S, Anderson RD, Jain SK, Polonsky TS, Ahmad FS, Roe MT, Rothman RL, Harrington RA, Hernandez AF, Jones WS. Aspirin Dosing for Secondary Prevention of Atherosclerotic Cardiovascular Disease in Patients Treated With P2Y12 Inhibitors. J Am Heart Assoc 2023; 12:e030385. [PMID: 37830344 PMCID: PMC10757508 DOI: 10.1161/jaha.123.030385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023]
Abstract
Background The ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) was a large, pragmatic, randomized controlled trial that found no difference between high- versus low-dose aspirin for secondary prevention of atherosclerotic cardiovascular disease. Whether concomitant P2Y12 inhibitor therapy modifies the effect of aspirin dose on clinical events remains unclear. Methods and Results Participants in ADAPTABLE were stratified according to baseline use of clopidogrel or prasugrel (P2Y12 group). The primary effectiveness end point was a composite of death, myocardial infarction, or stroke; and the primary safety end point was major bleeding requiring blood transfusions. We used multivariable Cox regression to compare the relative effectiveness and safety of aspirin dose within P2Y12 and non-P2Y12 groups. Of 13 815 (91.6%) participants with available data, 3051 (22.1%) were receiving clopidogrel (2849 [93.4%]) or prasugrel (203 [6.7%]) at baseline. P2Y12 inhibitor use was associated with higher risk of the primary effectiveness end point (10.86% versus 6.31%; adjusted hazard ratio [HR], 1.40 [95% CI, 1.22-1.62]) but was not associated with bleeding (0.95% versus 0.53%; adjusted HR, 1.42 [95% CI, 0.91-2.22]). We found no interaction in the relative effectiveness and safety of high- versus low-dose aspirin by P2Y12 inhibitor use. Overall, dose switching or discontinuation was more common in the high-dose compared with low-dose aspirin group, but the pattern was not modified by P2Y12 inhibitor use. Conclusions In this prespecified analysis of ADAPTABLE, we found that the relative effectiveness and safety of high- versus low-dose aspirin was not modified by baseline P2Y12 inhibitor use. Registration https://www.clinical.trials.gov. Unique identifier: NCT02697916.
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Affiliation(s)
- Saket Girotra
- University of Texas Southwestern Medical CenterDallasTX
| | - Amanda Stebbins
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
| | - Lisa Wruck
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
| | | | - Kamal Gupta
- University of Kansas Medical CenterKansas CityKS
| | | | | | | | | | | | | | | | | | | | - Faraz S. Ahmad
- Northwestern University Feinberg School of MedicineChicagoIL
| | - Matthew T. Roe
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
| | | | | | | | - W. Schuyler Jones
- Duke University Medical Center and Duke Clinical Research InstituteDurhamNC
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11
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Choi HH, Lee HS, Lee SH, Kim K, Cho WS, Kim JE, Kang HS. Delayed ischemic events with low-dose prasugrel medication for stent-assisted coil embolization in intracranial aneurysm patients. Neurosurg Focus 2023; 55:E12. [PMID: 37778045 DOI: 10.3171/2023.7.focus22654] [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: 12/06/2022] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Much emphasis has been put on the use of antiplatelet medication for the prevention of ischemic events in the treatment of cerebral aneurysms with stent assistance. In this regard, the effectiveness and safety of a low-dose prasugrel regimen during the periprocedural period was recently reported. The purpose of this study was to present the outcomes of patients on low-dose prasugrel regimens during the follow-up period after stent-assisted coil embolization (SACE) of cerebral aneurysms. METHODS For the 396 consecutive patients undergoing SACE procedures, low-dose prasugrel therapy (5 mg of prasugrel and 100 mg of aspirin) was recommended for 3 months after the endovascular treatment. The authors performed a retrospective review of a single-center experience focusing on delayed ischemic events beyond 1 month after treatment. The mean follow-up period was 24.6 ± 11.3 months. RESULTS In this cohort of patients on a low-dose prasugrel regimen, cerebral infarction occurred in 1 patient (0.3%, 95% CI 0%-1.8%) beyond 1 month after SACE. No intracranial hemorrhage occurred. Overall ischemic events occurred in 14 patients (3.5%, 95% CI 2.1%-5.9%), all within 6 months of the coiling procedure. All patients had transient symptoms. The events occurred within 2 months after cessation of prasugrel in 11 patients (78.6%). Prasugrel maintenance for 6 months was found to result in lower ischemic events compared with maintenance for 3 months. CONCLUSIONS For patients undergoing SACE, a low-dose prasugrel regimen was a safe and reliable treatment option for the prevention of delayed ischemic events. Transient ischemic events often occurred within 2 months of stopping prasugrel medication.
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Affiliation(s)
- Hyun Ho Choi
- 1Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Heui Seung Lee
- 2Department of Neurosurgery, Hallym University Medical Center, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea; and
| | - Sung Ho Lee
- 3Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kangmin Kim
- 3Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won-Sang Cho
- 3Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong Eun Kim
- 3Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- 3Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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12
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D'Ascenzo F, DE Filippo O, Angelini F, Piroli F, DE Lio G, Bocchino PP, Baldetti L, Melillo F, Chieffo A, Saglietto A, Omedè P, Montefusco A, Conrotto F, de Ferrari GM. Duration and kind of dual antiplatelet therapy for acute coronary syndrome patients: a network meta-analysis. Minerva Cardiol Angiol 2023; 71:494-503. [PMID: 35332750 DOI: 10.23736/s2724-5683.22.06038-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION For acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI), the choice of the duration and kind of dual antiplatelet therapy (DAPT) offering the most accurate balance between ischemic and bleeding risk remains unknown. EVIDENCE ACQUISITION A network meta-analysis was performed including all Randomized Controlled Trials (RCTs) comparing different DAPT regimens and duration in ACS patients undergoing PCI. Trial-defined MACE and major bleedings were the primary endpoints. Stroke, stent thrombosis (ST), all-cause and cardiovascular death, myocardial infarction (MI) represented secondary endpoints. EVIDENCE SYNTHESIS 13 RCTs encompassing 46145 patients were included. Mean age was 62 (61-64) years old, 42% being admitted with STEMI, 33% with NSTEMI and 25% with UA. The competitive arms were: clopidogrel and aspirin for 12 months (6 arms/18183 patients), clopidogrel and aspirin for 6 months (4/3329), clopidogrel and aspirin >12 months (3/2238), ticagrelor and aspirin for 12 months (6/12942) and prasugrel and aspirin for 12 months (3/9453). Trial-defined MACE and major bleedings, stroke and death were similar among the different arms. DAPT with prasugrel and aspirin for 12 months reduced MI compared to aspirin and clopidogrel for 12 months (OR 0.71, 95% CI: 0.54.0.94) and reduced the risk of ST compared to ticagrelor (OR 0.66, 95% CI: 0.49-0.90). Both prasugrel and ticagrelor reduced ST as compared to clopidogrel and aspirin for 12 months. CONCLUSIONS Different DAPT strategies yield similar risk of MACE, major bleeding, death and stroke in ACS patients. Prasugrel and aspirin for 12 months proved to be the most effective strategy regarding ST and MI.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Ovidio DE Filippo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy -
| | - Francesco Piroli
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giulia DE Lio
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pier P Bocchino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - Francesco Melillo
- Cardiac Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - Alaide Chieffo
- Unit of Interventional Cardiology, Department of Cardiology and Cardiothoracic Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Saglietto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Antonio Montefusco
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gaetano M de Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
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13
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Burgess SN, Shoaib A, Sharp ASP, Ludman P, Graham MM, Figtree GA, Kontopantelis E, Rashid M, Kinnaird T, Mamas MA. Sex-Specific Differences in Potent P2Y 12 Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI Patients. Circ Cardiovasc Interv 2023; 16:e012447. [PMID: 37725676 DOI: 10.1161/circinterventions.122.012447] [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: 10/19/2022] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Sex-based outcome differences for women with ST-segment-elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y12 inhibitors (P-P2Y12) is not well defined. This study explores the hypothesis that disparities in P-P2Y12 (prasugrel or ticagrelor) use may play a role in outcome disparities for women with STEMI. METHODS Data from British Cardiovascular Intervention Society national percutaneous coronary intervention database were analyzed, and 168 818 STEMI patients treated with primary percutaneous coronary intervention from 2010 to 2020 were included. RESULTS Among the included women (43 131; 25.54%) and men (125 687; 74.45%), P-P2Y12 inhibitors were prescribed less often to women (51.71%) than men (55.18%; P<0.001). Women were more likely to die in hospital than men (adjusted odds ratio, 1.213 [95% CI, 1.141-1.290]). Unadjusted mortality was higher among women treated with clopidogrel (7.57%), than P-P2Y12-treated women (5.39%), men treated with clopidogrel (4.60%), and P-P2Y12-treated men (3.61%; P<0.001). The strongest independent predictor of P-P2Y12 prescription was radial access (adjusted odds ratio, 2.368 [95% CI, 2.312-2.425]), used in 67.93% of women and 74.38% of men (P<0.001). Two risk adjustment models were used. Women were less likely to receive a P-P2Y12 (adjusted odds ratio, 0.957 [95% CI, 0.935-0.979]) with risk adjustment for baseline characteristics alone, when procedural factors including radial access were included in the model differences were not significant (adjusted odds ratio, 1.015 [95% CI, 0.991-1.039]). CONCLUSIONS Women were less likely to be prescribed prasugrel or ticagrelor, were less likely to have radial access, and had a higher mortality when being treated for STEMI. Improving rates of P-P2Y12 use and radial access may decrease outcome disparities for women with STEMI.
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Affiliation(s)
- Sonya N Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia (S.N.B.)
- University of Sydney, NSW, Australia (S.N.B.)
| | - Ahmad Shoaib
- Victoria Heart Institute Foundation (A.S.), Victoria, BC, Canada
- Royal Jubilee Hospital (A.S.), Victoria, BC, Canada
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
- Birmingham City Hospital, United Kingdom (A.S.)
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.L.)
| | - Michelle M Graham
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.)
| | - Gemma A Figtree
- Department of Cardiology, Kolling Institute, Royal North Shore Hospital and University of Sydney, Australia (G.A.F.)
| | | | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
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14
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Agrawal RS, Yusuf J, Mahajan B, Mehta V, Mandal S, Mukhopadhyay S. Effect of prasugrel versus ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive strategy - acute and short-term results. Coron Artery Dis 2023; 34:381-388. [PMID: 37471285 DOI: 10.1097/mca.0000000000001265] [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: 07/22/2023]
Abstract
INTRODUCTION Both ticagrelor and prasugrel are class I recommendations for treatment of ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) [ 1 ]. But clinical outcomes with the two drugs are conflicting which might be due to differential effects on coronary microcirculation. No study to date had compared the effects of prasugrel or ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive PCI (pPCI). AIM AND OBJECTIVE To compare the effects of prasugrel and ticagrelor on coronary microcirculation in STEMI patients undergoing pPCI as assessed by Myocardial Blush Grade (MBG). The secondary aim was to assess flow in the infarct-related artery by corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC) and whether a differential effect if detected on coronary microcirculation translated in improvement in left ventricular ejection fraction assessed at 6 months. MATERIAL AND METHODS A total of 240 patients with STEMI were evaluated in this open-label randomized control trial who initially underwent thrombolysis and later PCI (from 24 to 48 h) post-successful thrombolysis. The study subjects were randomized to receive either ticagrelor ( n = 120) or prasugrel ( n = 120) in 1 : 1 ratio 2 h prior to elective PCI. Patients underwent PCI according to standard protocol and post-procedure cTFC and MBG were compared. Patients were also followed up for 6 months to compare ejection fractions in both groups. We also assessed the effect of the two drugs on bleeding complications during hospitalization and over 6-month follow-up period. RESULTS There were no significant differences between the two groups with respect to baseline characteristics. Prasugrel administration resulted in higher MBG Grade 3 (50.86% vs 33.89%, P = 0.012) and lower cTFC (17.14 ± 4.08 vs 19.3 ± 4.06, P < 0.01). Improvement in ejection fraction was significantly higher with prasugrel compared to ticagrelor (10.29% ± 15.2 vs 4.66% ± 13.5, P = 0.003). Bleeding events at 6 months follow-up according to TIMI classification were similar in both the groups (11.86% vs 6.9%, P = 0.39). CONCLUSION Prasugrel produces greater improvement in coronary microcirculation than Ticagrelor resulting in improved myocardial salvage in patients of STEMI undergoing pPCI.
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Affiliation(s)
| | | | - Bhawna Mahajan
- Department of Biochemistry, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | | | - Sunil Mandal
- Department of Cardiology
- Department of Biochemistry, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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15
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Şen S. Comparison of bleeding risk between standard ticagrelor and prasugrel therapies without de-escalation strategy. Eur Heart J 2023; 44:3100-3101. [PMID: 37477371 DOI: 10.1093/eurheartj/ehad432] [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: 07/22/2023] Open
Affiliation(s)
- Selçuk Şen
- Division of Clinical Pharmacology, Department of Medical Pharmacology, Istanbul Faculty of Medicine, Istanbul University, Topkapı, Turgut Özal Millet Cd, 34093, Fatih/İstanbul, Turkey
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16
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Yildirim M, Mueller‐Hennessen M, Milles BR, Biener M, Hund H, Frey N, Giannitsis E, Salbach C. Real-World Evidence on Disparities on the Initiation of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome. J Am Heart Assoc 2023; 12:e030879. [PMID: 37581388 PMCID: PMC10492934 DOI: 10.1161/jaha.123.030879] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/20/2023] [Indexed: 08/16/2023]
Abstract
Background Management of patients with non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) is based on 2020 European Society of Cardiology guidelines, which recommend the preferential use of prasugrel over ticagrelor. Because the selection of the respective P2Y12 inhibitor has to consider label restrictions, we sought to evaluate the proportion of patients qualifying for either ticagrelor or prasugrel and reasons for noneligibility in an unselected cohort of patients with acute coronary syndrome. Methods and Results In this retrospective observational study, patients with ST-segment-elevation myocardial infarction (STEMI) or NSTE-ACS presenting consecutively during a 24-month period were enrolled. The eligibility of patients for a dual antiplatelet therapy option was assessed retrospectively. A total of 1502 patients had confirmed acute coronary syndrome (287 STEMI and 1215 NSTE-ACS). Eligibility for ticagrelor and full-dose prasugrel differed significantly for STEMI and NSTE-ACS (93% versus 51%, P<0.0001 versus 80% versus 31%, P<0.0001). Eligibility remained significantly lower (STEMI 78% versus NSTE-ACS 52%) if low-dose prasugrel was considered. Patients eligible for full-dose prasugrel had lower ischemic risk per GRACE (Global Registry of Acute Coronary Events) score (109 points [90-129 points] versus 121 points [98-146 points], P<0.0001) and lower bleeding risk (14 points [13-15 points] versus 20 points [12-29 points], P<0.0001) per PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy) score. Conclusions In real life, eligibility for prasugrel in patients requiring dual antiplatelet therapy is considerably lower than for ticagrelor, even in a cohort with high rates of coronary angiography and percutaneous coronary interventions. The recommended use of prasugrel over ticagrelor in current acute coronary syndrome guidelines contrasts with our observations of a substantial disparity on the eligibility. This important aspect has not received appropriate attention yet. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05774431.
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Affiliation(s)
- Mustafa Yildirim
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | | | - Barbara Ruth Milles
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Moritz Biener
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hauke Hund
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Norbert Frey
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Christian Salbach
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
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17
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Scudiero F, Canonico ME, Sanna GD, Dossi F, Silverio A, Galasso G, Esposito G, Porto I, Parodi G. Dual Antiplatelet Therapy with 3 rd Generation P2Y 12 Inhibitors in STEMI Patients: Impact of Body Mass Index on Loading Dose-Response. Cardiovasc Drugs Ther 2023; 37:695-703. [PMID: 35175499 DOI: 10.1007/s10557-022-07322-2] [Citation(s) in RCA: 2] [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] [Accepted: 02/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This study aims to assess the association between body mass index (BMI) and platelet reactivity in STEMI patients treated with oral 3rd generation P2Y12 inhibitors. METHODS Overall, 429 STEMI patients were enrolled in this study. Patients were divided into two groups according to BMI (BMI < 25 vs ≥ 25 kg/m2). A propensity score matching (1:1) was performed to balance potential confounders in patient baseline characteristics. Platelet reactivity was assessed by VerifyNow at baseline and after 3rd generation P2Y12 inhibitor (ticagrelor or prasugrel) loading dose (LD). Blood samples were obtained at baseline (T0), 1 h (T1), 2 h (T2), 4-6 h (T3), and 8-12 h (T4) after the LD. High on-treatment platelet reactivity (HTPR) was defined as a platelet reactivity unit value ≥ 208 units. RESULTS After propensity score matching, patients with BMI ≥ 25 had similar values of baseline platelet reactivity, while they had higher level of platelet reactivity at 1 and 2 h after the LD and higher rate of HRPT. Furthermore, multivariate analysis demonstrated that BMI ≥ 25 was an independent predictor of HTPR at 2 h (OR 2.01, p = .009). Conversely, starting from 4 h after the LD, platelet reactivity values and HRPT rates were comparable among the two study groups. CONCLUSIONS A BMI ≥ 25 kg/m2 is associated with delayed pharmacodynamic response to oral 3rd generation P2Y12 inhibitor LD, and it is a strong predictor of HTPR in STEMI patients treated by dual antiplatelet therapy with ticagrelor or prasugrel.
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Affiliation(s)
- Fernando Scudiero
- Medical Sciences Departement, Cardiology Unit, ASST Bergamo Est, Bolognini Hospital, Seriate, BG, Italy
| | - Mario E Canonico
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Giuseppe D Sanna
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Filippo Dossi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
- Cardiology Unit, ASL4 Liguria, Ospedali del Tigullio, Polo Di Lavagna, GE, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Guido Parodi
- Cardiology Unit, ASL4 Liguria, Ospedali del Tigullio, Polo Di Lavagna, GE, Italy.
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18
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Spagnolo M, Angiolillo DJ, Capodanno D. Evaluating the pharmacokinetic and pharmacodynamic impact of different modes of ticagrelor administration. Expert Opin Drug Metab Toxicol 2023; 19:769-784. [PMID: 37849294 DOI: 10.1080/17425255.2023.2272595] [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: 07/22/2023] [Accepted: 10/16/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Alternative administration modes for oral P2Y12 inhibitors, particularly ticagrelor, have emerged as a potential alternative to overcome the limitations associated with the delayed onset of action of these drugs in patients who are unable to swallow or with impaired absorption. AREAS COVERED This comprehensive literature review aims to provide an overview of the current state of knowledge on the pharmacokinetics and administration modes of ticagrelor, including factors that may affect its action. It also compares the pharmacokinetics of ticagrelor with that of other drugs with similar uses to provide a comprehensive understanding of the potential advantages and limitations of different modalities of P2Y12 administration. For this purpose, Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from database inception to July 2023. EXPERT OPINION Among the different alternatives, crushed formulations, especially for ticagrelor, have emerged as the most promising option, showing early and robust platelet inhibition. However, important questions remain unanswered, such as the comparative clinical benefits of crushed ticagrelor versus standard administration, the cost-effectiveness of alternative modes compared to intravenous P2Y12 inhibitors such as cangrelor, and the important limitations associated with the concomitant use of opioids, who have been proven to impair even the action of crushed ticagrelor.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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19
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Kitazono T, Kamouchi M, Matsumaru Y, Shirai T, Takita A, Kuroda T, Kimura K. Comparison of Prasugrel and Clopidogrel in Thrombotic Stroke Patients with Risk Factors for Ischemic Stroke Recurrence: An Integrated Analysis of PRASTRO-I, PRASTRO-II, and PRASTRO-III. Cerebrovasc Dis 2023; 52:720-729. [PMID: 37011599 DOI: 10.1159/000529149] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/05/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION Patients with stroke are at a high risk of recurrence, and although they receive antiplatelet therapies such as clopidogrel for secondary prevention of non-cardioembolic stroke, the recurrence rate remains high. Three phase 3 trials (PRASTRO-I/II/III) were conducted to determine the efficacy of prasugrel in preventing recurrent stroke. Here, we performed an integrated analysis of these studies to confirm the generalizability of the PRASTRO-III findings and to supplement the small sample size of the study. METHODS Patients from PRASTRO-I, PRASTRO-II, and PRASTRO-III with ischemic stroke (large-artery atherosclerosis or small-artery occlusion) and at least one of the following were included: hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease, or ischemic stroke history. The primary efficacy endpoint was the composite incidence of ischemic stroke, myocardial infarction (MI), and death from other vascular causes in the intention-to-treat population. Bleeding events (life-threatening bleeding, major bleeding, and clinically relevant bleeding) were evaluated as the primary safety endpoint. Cumulative incidences and 95% confidence intervals (CIs) were calculated for the study outcomes using the Kaplan-Meier method. Hazard ratios (HRs) and 95% CIs were calculated using the Cox regression model. RESULTS The data of 2,184, 274, and 230 patients from PRASTRO-I, PRASTRO-II, and PRASTRO-III, respectively, were analyzed (N = 2,688; prasugrel, N = 1,337; clopidogrel, N = 1,351). Stroke at enrollment was classified as large-artery atherosclerosis in 49.3% of patients and small-artery occlusion in 50.7% of patients. The primary efficacy endpoint composite incidence (prasugrel vs. clopidogrel) was 3.4% versus 4.3% (HR: 0.771, 95% CI: 0.522-1.138). The incidence of each component of the primary efficacy endpoint for prasugrel versus clopidogrel was 3.1% (n = 41) versus 4.1% (n = 55) for ischemic stroke, 0.3% (n = 4) versus 0.2% (n = 3) for MI, and no events of death from other vascular causes. For the primary safety endpoint, bleeding events were reported in 6.0% of patients in the prasugrel group versus 5.5% of patients in the clopidogrel group (HR: 1.074, 95% CI: 0.783-1.473). CONCLUSIONS This integrated analysis supports the findings of PRASTRO-III. Prasugrel is a promising treatment that results in a numerical reduction in the composite incidence of ischemic stroke, MI, and death from other vascular causes in patients with ischemic stroke who are at a high risk of stroke recurrence. No major safety issues were observed for prasugrel.
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Affiliation(s)
- Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Toshiaki Shirai
- Development Function, Development Management Group, Daiichi Sankyo Co. Ltd., Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co. Ltd., Tokyo, Japan
| | - Takeshi Kuroda
- Primary Medical Science Department, Daiichi Sankyo Co. Ltd., Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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20
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Koch T, Lahu S, Coughlan JJ, Cassese S, Voll F, Ndrepepa G, Menichelli M, Valina C, Hemetsberger R, Witzenbichler B, Bernlochner I, Joner M, Xhepa E, Mayer K, Kessler T, Laugwitz KL, Richardt G, Schunkert H, Angiolillo DJ, Sibbing D, Kastrati A, Kufner S. Association between Platelet Count and Treatment Effect of Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. Thromb Haemost 2023; 123:464-477. [PMID: 36442805 PMCID: PMC10060058 DOI: 10.1055/a-1988-5047] [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: 05/17/2022] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The relative efficacy and safety of ticagrelor and prasugrel based dual antiplatelet therapy strategies according to the platelet count (PC) in patients with acute coronary syndromes (ACS) have not been defined. METHODS This is a posthoc analysis of the ISAR-REACT 5 trial, in which patients presenting with ACS were randomized to treatment with ticagrelor versus prasugrel. Patients were divided into quartiles according to PC. The primary endpoint was incidence of death, myocardial infarction, or stroke, and the safety endpoint was incidence of BARC (Bleeding Academic Research Consortium) type 3 to 5 bleeding at 12 months. RESULTS A total of 3,943 patients with known PC (997 patients in quartile 1 (Q1), 1,003 in quartile 2 (Q2) [205 ± 10.3 × 109/L], 961 patients in quartile 3 (Q3) [241 ± 11.7 × 109/L], and 982 patients in quartile 4 (Q4) [317 ± 68.6 × 109/L]). There was no significant interaction between treatment arm (ticagrelor vs. prasugrel) and PC group with respect to primary endpoint (Q1: 8.8 vs. 6.3%, hazard ratio [HR] =1.41, 95% confidence interval [CI]: 0.89-2.23; p = 0.148; Q2: 9.9 vs. 5.8%, HR = 1.68, 95% CI: 1.06-2.66; p = 0.027; Q3: 7.8 vs. 5.5%, HR = 1.43, 95% CI: 0.87-2.37; p = 0.159; Q4: 10.1 vs. 10.1%, HR = 1.05, 95% CI: 0.71-1.57; p = 0.799; p for interaction [p int] = 0.482) and with respect to bleeding endpoint (Q1: 5.8 vs. 4.2%, HR = 1.41, 95% CI: 0.76-2.63; p = 0.279; Q2: 6.4 vs. 3.7%, HR = 1.62, 95% CI: 0.85-2.06; p = 0.140; Q3: 4.4 vs. 3.0%, HR = 1.53, 95% CI: 0.73-3.18; p = 0.258; Q4: 5.6 vs. 8.5%, HR = 0.67, 95% CI: 0.40-1.14; p = 0.138, p int = 0.102). CONCLUSIONS In this analysis, incidences of ischemic and bleeding events at 12 months are comparable across quartiles of platelet count.
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Affiliation(s)
- Tobias Koch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Shqipdona Lahu
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - J. J. Coughlan
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Felix Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany
| | - Rayyan Hemetsberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Katharina Mayer
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Thorsten Kessler
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Gert Richardt
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität München, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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Sabouret P, Spadafora L, Fischman D, Ullah W, Zeitouni M, Gulati M, De Rosa S, Savage MP, Costabel JP, Banach M, Biondi-Zoccai G, Galli M. De-escalation of antiplatelet therapy in patients with coronary artery disease: Time to change our strategy? Eur J Intern Med 2023; 110:1-9. [PMID: 36575107 DOI: 10.1016/j.ejim.2022.12.008] [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: 11/05/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
Dual antiplatelet therapy (DAPT) is the gold standard after acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI). Because local and systemic ischemic complications can occur particularly in the early phase (i.e. 1-3 months) after ACS or PCI, the synergistic platelet inhibition of aspirin and a P2Y12 inhibitor is of the utmost importance in this early phase. Moreover, the use of the more potent P2Y12 inhibitors prasugrel and ticagrelor have shown to further reduce the incidence of ischemic events compared to clopidogrel after an ACS. On the other hand, prolonged and potent antiplatelet therapy are inevitably associated with increased bleeding, which unlike thrombotic risk, tends to be stable over time and may outweigh the benefit of reducing ischemic events in these patients. The duration and composition of antiplatelet therapy remains a topic of debate in cardiology due to competing ischemic and bleeding risks, with guidelines and recommendations considerably evolving in the past years. An emerging strategy, called "de-escalation", consisting in the administration of a less intense antithrombotic therapy after a short course of standard DAPT, has shown to reduce bleeding without any trade-off in ischemic events. De-escalation may be achieved with different antithrombotic strategies and can be either unguided or guided by platelet function or genetic testing. The aim of this review is to summarize the evidence and provide practical recommendations on the use of different de-escalation strategies in patients with ACS and CCS.
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Affiliation(s)
- Pierre Sabouret
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France; Collège National des Cardiologues Français (CNCF), Paris, France.
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - David Fischman
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Waqas Ullah
- Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Michel Zeitouni
- Heart Institute, ACTION Study Group-CHU Pitié-Salpétrière, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, USA
| | | | | | - Juan Pablo Costabel
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires (ICBA), Buenos Aires, Argentina
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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22
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ten Haaf ME, van Geuns RJM, van der Linden MM, Smits PC, de Vries AG, Doevendans PA, Appelman Y, Boersma E. Sex-Related Bleeding Risk in Acute Coronary Syndrome Patients Receiving Dual Antiplatelet Therapy with Aspirin and a P2Y12 Inhibitor. Med Princ Pract 2023; 32:200-208. [PMID: 36948164 PMCID: PMC10601701 DOI: 10.1159/000529863] [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: 07/19/2022] [Accepted: 02/06/2023] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE The aim of this work was to study sex differences in major bleeding risk in relation to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). METHODS AND RESULTS The Rijnmond Collective Cardiology Research registry was designed to evaluate the application and outcomes of DAPT after ACS/PCI in the Rijnmond region in the Netherlands. Overall, 1,172 women (median age 67.5 years) and 3,087 men (median age 62.2 years) with ACS/PCI were enrolled between August 2011 and June 2013. Based on a tailored regional DAPT guideline aiming at bleeding risk minimization, 52.6% women and 66.9% men received prasugrel as first-choice P2Y12 inhibitor, in addition to aspirin. Women more frequently had contraindications for the use of prasugrel (and therefore received clopidogrel) than men (47.9 vs. 26.9%, p < 0.001). Femoral access was more common in women than in men (47.6 vs. 38.1%, p < 0.001). Women had higher incidence of major bleeding at 1 year than men (2.6 vs. 1.6%, p = 0.018). After adjustment for established bleeding risk factors, female sex was associated with over two-fold higher risk of major bleeding (adjusted hazard ratio 2.33; 95% confidence interval 1.26-4.32). This difference was apparent at discharge and appeared to be caused by access site bleedings (0.9 vs. 0.1%, p < 0.001). No sex differences were found in non-access site-related major bleeding up to 1 year. CONCLUSION Women with ACS/PCI receiving DAPT had higher major bleeding risk caused by an excess in access site bleeds, mainly in relation to the femoral approach.
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Affiliation(s)
- Monique E. ten Haaf
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- The Netherlands Heart Institute, Utrecht, The Netherlands
| | | | | | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Arie G. de Vries
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Pieter A. Doevendans
- The Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
- Cardiovascular Research School Erasmus University Rotterdam (COEUR), Rotterdam, The Netherlands
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23
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Gumiężna K, Baruś P, Sygitowicz G, Wiśniewska A, Ochijewicz D, Pasierb K, Klimczak-Tomaniak D, Kuca-Warnawin E, Kochman J, Grabowski M, Opolski G, Tomaniak M, Filipiak KJ. Immature platelet fraction in cardiovascular diagnostics and antiplatelet therapy monitoring. Cardiol J 2023; 30:817-824. [PMID: 36908161 PMCID: PMC10635728 DOI: 10.5603/cj.a2023.0019] [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: 04/15/2022] [Revised: 09/11/2022] [Accepted: 12/09/2022] [Indexed: 03/14/2023] Open
Abstract
Immature platelet fraction (IPF), circulating platelets still containing RNA, can be easily calculated by automated flow cytometry, this makes them an accessible biomarker. Higher IPF concentrations were reported in patients with thrombocytopenia, patients who were smokers, and also those who were diabetics. Several studies have reported their diagnostic and prognostic importance in patients presenting with acute coronary syndromes, especially ST-segment elevation myocardial infarction, where increased IPF level is an independent predictor of cardiovascular death. In addition, higher IPF were reported in patients with inadequate response to either clopidogrel or prasugrel, suggesting their potential role in antiplatelet therapy monitoring. Their prognostic significance was also observed in both coronary artery disease and postcardiac surgery status, where their higher levels correlated with the risk of major adverse cardiac events. The current review aims to present the current evidence on diagnostic, prognostic and potentially therapeutic roles of IPF in cardiovascular medicine.
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Affiliation(s)
- Karolina Gumiężna
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Piotr Baruś
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Grażyna Sygitowicz
- Department of Clinical Chemistry and Laboratory Diagnostics, Medical University of Warsaw, Poland
| | | | - Dorota Ochijewicz
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Karolina Pasierb
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Dominika Klimczak-Tomaniak
- Department of Cardiology, Hypertension and Internal Medicine, Medical University of Warsaw, Poland
- Department of Immunology, Transplantation and Internal Medicine, Medical University of Warsaw, Poland
| | - Ewa Kuca-Warnawin
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Marcin Grabowski
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Grzegorz Opolski
- First Department of Cardiology, Medical University of Warsaw, Poland
| | - Mariusz Tomaniak
- First Department of Cardiology, Medical University of Warsaw, Poland.
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Ingrassia JJ, Mosleh W, Conner CM, Mather JF, Loya DS, Yaffee DW, Sutton TS, Takata ET, McMahon SR, Hashim SW, McKay RG. Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting. Cardiovasc Revasc Med 2023; 46:44-51. [PMID: 35961855 DOI: 10.1016/j.carrev.2022.08.005] [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: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.
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Affiliation(s)
- Joseph J Ingrassia
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Chad M Conner
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - David W Yaffee
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sabet W Hashim
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA.
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Wöhrle J, Seeger J. Prasugrel and Ticagrelor Treatment Among Patients With ACS: Is There a Need for a New Randomized Trial? JACC Cardiovasc Interv 2022; 15:2281-2283. [PMID: 36423971 DOI: 10.1016/j.jcin.2022.10.019] [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: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany.
| | - Julia Seeger
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
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26
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Lahu S, Presch A, Ndrepepa G, Menichelli M, Valina C, Hemetsberger R, Witzenbichler B, Bernlochner I, Joner M, Xhepa E, Hapfelmeier A, Kufner S, Rifatov N, Sager HB, Mayer K, Kessler T, Laugwitz KL, Richardt G, Schunkert H, Neumann FJ, Sibbing D, Angiolillo DJ, Kastrati A, Cassese S. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndrome and High Bleeding Risk. Circ Cardiovasc Interv 2022; 15:e012204. [PMID: 36256695 DOI: 10.1161/circinterventions.122.012204] [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] [Indexed: 01/10/2023]
Abstract
BACKGROUND The relative efficacy and safety of more potent P2Y12 inhibitors in patients with acute coronary syndrome and high bleeding risk (HBR) undergoing percutaneous coronary intervention remains unclear. We aimed to study the treatment effect of ticagrelor and prasugrel in percutaneous coronary intervention patients presenting with acute coronary syndrome and HBR. METHODS This post hoc analysis of the ISAR-REACT 5 trial (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5) included patients with acute coronary syndrome undergoing percutaneous coronary intervention, randomized to ticagrelor or prasugrel, in whom HBR was defined as per Academic Research Consortium criteria. The primary (efficacy) end point was the composite of all-cause death, myocardial infarction, or stroke. The secondary (safety) end point was Bleeding Academic Research Consortium type 3 to 5 bleeding. Outcomes were assessed 12 months after randomization. RESULTS Out of the 3239 patients included in this analysis, 486 fulfilled the criteria for Academic Research Consortium-HBR definition (HBR group; ticagrelor, n=230 and prasugrel, n=256), while 2753 did not (non-HBR group; ticagrelor, n=1375 and prasugrel, n=1378). Compared with the non-HBR group, the HBR group had a higher risk for the primary (hazard ratio [HR]=3.57 [95% CI, 2.79-4.57]; P<0.001) and secondary end point (HR=2.94 [2.17-3.99]; P<0.001). In the HBR group, the primary (HR=1.09 [0.73-1.62]) and secondary (HR=1.18 [0.67-2.08]) end points were not significantly different between patients assigned to ticagrelor and prasugrel. In the non-HBR group, the primary end point (HR=1.62 [1.19-2.20]) occurred more frequently in patients assigned to ticagrelor as compared to patients assigned to prasugrel, without difference in safety (HR=1.08 [0.74-1.58]). There was no significant treatment allocation-by-HBR status interaction with respect to the primary (P for interaction=0.12) or secondary (P for interaction=0.80) end points. CONCLUSIONS In patients with acute coronary syndrome undergoing percutaneous coronary intervention, HBR status increased both ischemic and bleeding risk without significant impact on the relative efficacy and safety of either ticagrelor or prasugrel. These results warrant confirmation in larger cohorts. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Antonia Presch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany (C.V., F.-J.N.)
| | - Rayyan Hemetsberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (R.H.)
| | | | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (I.B., K.-L.L.)
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute for AI and Informatics in Medicine, Germany (A.H.)
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Germany (A.H.)
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Nonglag Rifatov
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Hendrik B Sager
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Katharina Mayer
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Thorsten Kessler
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (I.B., K.-L.L.)
| | - Gert Richardt
- Heart Center Bad Segeberg, Segeberger Kliniken GmbH, Bad Segeberg, Germany (G.R.)
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany (C.V., F.-J.N.)
| | - Dirk Sibbing
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München (D.S.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
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Lahu S, Ndrepepa G, Neumann FJ, Menichelli M, Bernlochner I, Richardt G, Wöhrle J, Witzenbichler B, Hemetsberger R, Mayer K, Akin I, Cassese S, Gewalt S, Xhepa E, Kufner S, Valina C, Sager HB, Joner M, Ibrahim T, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A. Pre-admission antiplatelet therapy and treatment effect of ticagrelor vs. prasugrel in patients with acute coronary syndromes-a subgroup analysis of the ISAR-REACT 5 trial. Eur Heart J Cardiovasc Pharmacother 2022; 8:687-694. [PMID: 35191982 DOI: 10.1093/ehjcvp/pvac007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/18/2022] [Indexed: 06/14/2023]
Abstract
AIMS To assess whether the efficacy and safety of ticagrelor vs. prasugrel in patients with acute coronary syndromes (ACSs) are influenced by pre-admission treatment with aspirin and/or clopidogrel. METHODS AND RESULTS Patients (n = 4018) were categorized into two groups: pre-admission aspirin and/or clopidogrel group (n = 1455) and no pre-admission aspirin or clopidogrel group (n = 2563). The primary endpoint was the composite of all-cause death, myocardial infarction, or stroke; the secondary safety endpoint was Bleeding Academic Research Consortium (BARC) type 3-5 bleeding, both at 1 year. Patients in the pre-admission aspirin and/or clopidogrel group had a higher risk of ischaemic events, but a similar risk of bleeding to patients in the no pre-admission aspirin or clopidogrel group (cumulative incidences 10.5% vs. 6.7%, and 5.7% vs. 5.7%, respectively). The primary endpoint occurred in 81/717 patients assigned to ticagrelor and 69/738 patients assigned to prasugrel in the pre-admission aspirin and/or clopidogrel group [11.5% vs. 9.5%; hazard ratio (HR) = 1.23; 95% confidence interval (CI) 0.89-1.69], and in 103/1295 patients assigned to ticagrelor and 68/1268 patients assigned to prasugrel in the no pre-admission aspirin or clopidogrel group [8.0% vs. 5.4%; HR = 1.50 (1.10-2.03); Pint = 0.38]. BARC type 3-5 bleeding events did not differ between ticagrelor and prasugrel in patients in the pre-admission aspirin and/or clopidogrel (6.2% vs. 4.5%) or no pre-admission aspirin or clopidogrel (5.3% vs. 5.1%) group (Pint = 0.54). CONCLUSION In patients with ACS, pre-admission therapy with aspirin and/or clopidogrel has no influence on the relative efficacy and safety of ticagrelor and prasugrel.
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Affiliation(s)
- Shqipdona Lahu
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | - Isabell Bernlochner
- I. Medizinische Klinik und Poliklinik Innere Medizin, Klinikum Rechts der Isar, Munich, Germany
| | | | - Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
| | | | | | - Katharina Mayer
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Senta Gewalt
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Hendrik B Sager
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Tareq Ibrahim
- I. Medizinische Klinik und Poliklinik Innere Medizin, Klinikum Rechts der Isar, Munich, Germany
| | - Karl-Ludwig Laugwitz
- I. Medizinische Klinik und Poliklinik Innere Medizin, Klinikum Rechts der Isar, Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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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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Lahu S, Behnes M, Ndrepepa G, Neumann FJ, Sibbing D, Bernlochner I, Menichelli M, Mayer K, Richardt G, Gewalt S, Angiolillo DJ, Coughlan JJ, Aytekin A, Witzenbichler B, Hochholzer W, Cassese S, Kufner S, Xhepa E, Sager HB, Joner M, Fusaro M, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A, Akin I. Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes. Rev Esp Cardiol (Engl Ed) 2022; 75:747-755. [PMID: 34961732 DOI: 10.1016/j.rec.2021.11.007] [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] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES The efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI. METHODS Patients (n=3987) were grouped into 3 categories: normal weight (BMI <25kg/m2; n=1084), overweight (BMI ≥ 25 to <30kg/m2; n=1890), and obesity (BMI ≥ 30kg/m2; n=1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding. RESULTS The primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P=.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P=.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P=.451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P=.990), overweight (5.6% vs 5.0%; P=.566) or obesity (4.4% vs 2.8%; P=.219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=.578) or secondary endpoint (Pint=.596). CONCLUSIONS In patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety. CLINICAL TRIAL REGISTRATION NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gjin Ndrepepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Cardiology, Klinik der Universität München, Ludwig - Maximilians - University, Munich, Germany
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | | | - Katharina Mayer
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gert Richardt
- Department of Cardiology and Angiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Senta Gewalt
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - John Joseph Coughlan
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alp Aytekin
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Salvatore Cassese
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Hendrik B Sager
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Joner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Massimiliano Fusaro
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | - Heribert Schunkert
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Stefanie Schüpke
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Adnan Kastrati
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Kitahara H, Tateishi K, Shiko Y, Inaba Y, Kobayashi Y, Inoue T. Comparison of short-term clinical outcomes between low-dose prasugrel and clopidogrel as part of triple antithrombotic therapy in patients requiring oral anticoagulant therapy and percutaneous coronary intervention. PLoS One 2022; 17:e0272140. [PMID: 35901007 PMCID: PMC9333269 DOI: 10.1371/journal.pone.0272140] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/13/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Triple antithrombotic therapy, including dual antiplatelet therapy and oral anticoagulant (OAC), is recommended for a short-term period after percutaneous coronary intervention (PCI) in patients requiring anticoagulation therapy. The purpose of this study was to compare in-hospital clinical outcomes between low-dose prasugrel (3.75 mg/day) and clopidogrel, as part of triple antithrombotic therapy, using a large database in Japan. METHODS Patients with ischemic heart disease who underwent PCI between January 2015 and December 2019, and were prescribed triple therapy with aspirin, a P2Y12 inhibitor (clopidogrel or low-dose prasugrel), and OAC (direct oral anticoagulant: DOAC or vitamin K antagonist: VKA), were selected from the Diagnosis Procedure Combination database. The primary outcome was in-hospital mortality. The secondary outcomes were myocardial infarction, ischemic stroke, bleeding stroke, gastrointestinal bleeding, and blood transfusion. RESULTS Overall, 5,777 patients were eligible in this analysis. The patients were divided into 4 subgroups according to the type of P2Y12 inhibitor and OAC: clopidogrel/DOAC (n = 1,628), clopidogrel/VKA (n = 1,334), prasugrel/DOAC (n = 1,607), and prasugrel/VKA (n = 1,208). There was no significant difference in the incidence of death and gastrointestinal bleeding among the 4 subgroups. The prasugrel/DOAC group had significantly lower incidence of MI (OR 0.566, 95% CI 0.348-0.921). The incidence of ischemic stroke was significantly lower in the prasugrel/DOAC group (OR 0.701, 95% CI 0.502-0.979), and significantly higher in the clopidogrel/VKA group (OR 1.680, 95% CI 1.273-2.216). Need for blood transfusion was less frequent in the prasugrel/DOAC group (OR 0.729, 95% CI 0.598-0.890), and more frequent in both the clopidogrel/VKA group (OR 1.424, 95% CI 1.187-1.708) and the prasugrel/VKA group (OR 1.633, 95% CI 1.367-1.950). CONCLUSIONS Combination of low-dose prasugrel and DOAC was associated with lower incidence of MI, ischemic stroke, and blood transfusion. Low-dose prasugrel may be feasible as part of triple therapy in patients undergoing PCI.
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Affiliation(s)
- Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yusuke Inaba
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takahiro Inoue
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan
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Yan L, Zhou Y, Yu Z, Xuan M, Xu B, Peng F. P2Y12 inhibitor pretreatment in patients with nonST-segment elevation acute coronary syndrome: A meta-analysis. Medicine (Baltimore) 2022; 101:e29824. [PMID: 35801776 PMCID: PMC9259160 DOI: 10.1097/md.0000000000029824] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The 2020 European Society of Cardiology guidelines do not recommend pretreatment for nonST-segment elevation myocardial infarction (NSTEMI) patients with unclear coronary anatomy, which is inconsistent with our routine preoperative approach to loading P2Y12 receptor inhibitors (e.g., preoperative loading of 300 mg of clopidogrel). OBJECTIVES The purpose of our study was to compare the safety and effectiveness of P2Y12 inhibitors administered before coronary angiography or at least before percutaneous coronary intervention (PCI) with during or after PCI. METHODS Cochrane, PubMed, and Embase databases were searched. The primary effect endpoint and safety endpoint were any-cause death and major bleeding, respectively. Major adverse cardiovascular events, myocardial infarction and revascularization were also analyzed. RESULTS Our search identified 9 trials. P2Y12 inhibitor pretreatment was associated with lower death from any cause (OR 0.62, 95% CI 0.53-0.72, P < 0.00001) without increasing the risk of bleeding (OR 1.02, 95% CI 0.80-1.30, P = 0.89). However, prasugrel or ticagrelor pretreatment was not associated with a lower risk of mortality (OR 0.70, 95% CI 0.31-1.59, P = 0.40) and increased the risk of bleeding (OR 1.67, 95% CI 1.10-2.54, P = 0.02). CONCLUSIONS In summary, clopidogrel pretreatment was associated with significantly lower mortality, major adverse cardiovascular events, myocardial infarction and revascularization with no increase in major bleeding. However, these advantages were not observed with prasugrel or ticagrelor pretreatment.
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Affiliation(s)
- Longhui Yan
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Yan Zhou
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Zhangjie Yu
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Mengmei Xuan
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
| | - Buyun Xu
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
- *Correspondence: Fang Peng (e-mail: ), Buyun Xu (e-mail: )
| | - Fang Peng
- Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of medicine), Shaoxing, Zhejiang Province, P.R. China
- *Correspondence: Fang Peng (e-mail: ), Buyun Xu (e-mail: )
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Abdelazeem B, Shehata J, Abbas KS, El-Shahat NA, Baral N, Adhikari G, Khan H, Hassan M. De-escalation from Prasugrel or Ticagrelor to Clopidogrel in Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention: An Updated Meta-analysis of Randomized Clinical Trials. Am J Cardiovasc Drugs 2022; 22:287-298. [PMID: 34651261 DOI: 10.1007/s40256-021-00504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION We aimed to evaluate the clinical benefits of a de-escalation strategy from prasugrel or ticagrelor to clopidogrel versus continuation of prasugrel or ticagrelor along with aspirin in both strategies for patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI), and to analyze the effect of the recently published randomized clinical trial (RCT) by Park et al., which included the largest sample size ever and the largest switched number of patients, on current guidelines and practices. DATA SOURCES The PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar databases were searched systematically from inception to May 2021 by using the search terms ('de-escalation' OR 'switching') AND ('antiplatelet' OR 'clopidogrel' OR 'ticagrelor' OR 'prasugrel') AND ('percutaneous coronary intervention' OR 'PCI'' OR 'Acute coronary syndrome' OR 'ACS'). STUDY SELECTION AND DATA EXTRACTION We included RCTs that reported the primary outcomes, i.e. net clinical benefits and Bleeding Academic Research Consortium (BARC) type 2 or higher bleeding. A combination of both ischemic and bleeding events was defined as a net clinical benefit. DATA SYNTHESIS A total of four RCTs were included, with 5952 patients. A random-effects meta-analysis revealed that a de-escalation strategy was associated with lower ischemic and bleeding events (net clinical benefits; risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.85; p = 0.003), and lower BARC type 2 or higher bleeding (RR 0.51, 95% CI 0.29-0.91; p = 0.02) when compared with a continuation strategy. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The current guidelines recommend potent P2Y12 prasugrel or ticagrelor for 12 months despite their association with a high risk of bleeding. Our meta-analysis updates cardiologists, providing them with the best available evidence in managing patients with ACS who underwent PCI. CONCLUSION Among patients with ACS treated with PCI, a de-escalation strategy (prasugrel or ticagrelor to clopidogrel) is associated with lower ischemic and bleeding events (net clinical benefits) and lower BARC type 2 or higher bleeding; however, due to the limited number of included studies, further high-quality studies are needed to establish the clinical efficacy of the de-escalation strategy.
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Affiliation(s)
- Basel Abdelazeem
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA.
| | | | | | | | - Nischit Baral
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Govinda Adhikari
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Hafiz Khan
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Mustafa Hassan
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
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Farmakis IT, Zafeiropoulos S, Doundoulakis I, Pagiantza A, Karagiannidis E, Moysidis DV, Stalikas N, Kassimis G, Michalis LK, Karvounis H, Giannakoulas G. Comparative efficacy and safety of oral P2Y 12 inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis. Open Heart 2022; 9:openhrt-2021-001937. [PMID: 35428703 PMCID: PMC9014125 DOI: 10.1136/openhrt-2021-001937] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/31/2022] [Indexed: 11/20/2022] Open
Abstract
Background Currently, potent P2Y12 inhibition with the use of prasugrel or ticagrelor is the mainstay of treatment after an acute coronary syndrome (ACS). The 2020 European Society of Cardiology (ESC) Guidelines recommend the use of prasugrel over ticagrelor in patients with non-ST-elevation ACS (NSTE-ACS) intended to receive invasive management (class IIa recommendation), however there are contradictory views regarding this recommendation. Aim To compare oral P2Y12 inhibitors in NSTE-ACS in terms of efficacy and safety with a focus on patients intended to proceed to invasive management. Methods We systematically searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) in patients with NSTE-ACS. Efficacy outcomes included the major adverse cardiovascular events outcome and safety outcomes included minor and major bleedings. We performed a frequentist network meta-analysis. Results Nine studies (n=35 441 patients) were included in the systematic review. There was no difference between prasugrel and ticagrelor in the composite cardiovascular end point (prasugrel vs ticagrelor HR=0.80, 95% CI=0.61 to 1.06) in all patients with NSTE-ACS. In patients intended to receive invasive management, prasugrel resulted in a reduction of the composite cardiovascular end point both versus clopidogrel (HR=0.76, 95% CI=0.61 to 0.95) and ticagrelor (HR=0.74, 95% CI=0.56 to 0.98). Inconsistency was moderate and non-significant (I2=27%, total Q p=0.2). Prasugrel ranked as the most efficient treatment in the composite cardiovascular efficacy outcome, all-cause death, myocardial infarction and definite stent thrombosis, while clopidogrel ranked as safest in the bleeding outcomes. Conclusion In patients with NSTE-ACS intended to receive invasive management, an antiplatelet strategy based on prasugrel is more efficient than a similar strategy based on ticagrelor on a moderate level of evidence. This analysis supports the current recommendations by the ESC guidelines.
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Affiliation(s)
- Ioannis T Farmakis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Ioannis Doundoulakis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Areti Pagiantza
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstratios Karagiannidis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Stalikas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lampros K Michalis
- Second Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, Ioannina, Greece
| | - Haralambos Karvounis
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Schoerghuber M, Pregartner G, Berghold A, Lindenau I, Zweiker R, Voetsch A, Mahla E, Zirlik A. How do type of preoperative P2Y 12 receptor inhibitor and withdrawal time affect bleeding? Protocol of a systematic review and individual patient data meta-analysis. BMJ Open 2022; 12:e060404. [PMID: 35351733 PMCID: PMC8961154 DOI: 10.1136/bmjopen-2021-060404] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION In order to reduce the risk of bleeding in patients on P2Y12 receptor inhibitors presenting for non-emergent coronary artery bypass grafting (CABG), current guidelines recommend a preoperative discontinuation period of at least three, five and seven days for ticagrelor, clopidogrel and prasugrel, respectively, to allow for recovery of platelet function. However, there is still substantial interinstitutional variation in preoperative management and relevant covariates of CABG-related bleeding are largely elusive so far. METHODS AND ANALYSIS We will search PubMed (July 2013 to November 2021) and EMBASE (January 2014 to November 2021) using the following terms, MeSH terms and their synonyms: clopidogrel, prasugrel, ticagrelor, dual antiplatelet, P2Y12 receptor inhibitor, CABG, bleeding, haemorrhage. Two independent reviewers will screen all abstracts and full papers for eligibility. Disagreements will be solved by consulting with a third reviewer.The primary outcome is the incidence of Bleeding Academic Research Consortium type-4 bleeding depending on type of P2Y12 receptor inhibitor and preoperative withdrawal period. The secondary outcomes are mortality and ischaemic events according to the Academic Research Consortium 2 Consensus Document. We will perform an individual patient data meta-analysis (IPD-MA) with drug-specific preoperative withdrawal time and adjust for demographic and procedural variables. Subgroup analyses will be performed for anaemic patients and patients undergoing non-emergent versus urgent/emergent surgery. ETHICS AND DISSEMINATION This IPD-MA consists of secondary analyses of existing non-identifiable data and meets the criteria for waiver of ethics review by the local Research Ethics Committee. Data sharing and transfer will be subject to a confidentiality agreement and a data use agreement. Findings will be disseminated through peer-reviewed publication and conference presentation. PROSPERO REGISTRATION NUMBER CRD42022291946.
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Affiliation(s)
- Michael Schoerghuber
- Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Ines Lindenau
- Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
- Department of Anesthesiology and Intensive Care Medicine, Hospital Hochsteiermark, Steiermarkische Krankenanstaltengesellschaft mbH, Leoben, Austria
| | - Robert Zweiker
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Voetsch
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Elisabeth Mahla
- Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Zirlik
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Gorgis S, Lemor A, Kolski B, Lalonde T, Kaki A, Marso S, Senter S, Rahman A, Gorwara S, Nazir R, Zuberi O, Justice L, Srivastava N, Padgett R, O'Neill W, Basir MB. Antiplatelet Therapy in Acute Myocardial Infarction and Cardiogenic Shock: Insights From the National Cardiogenic Shock Initiative. J Invasive Cardiol 2022; 34:E156-E163. [PMID: 35157607] [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] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Patients presenting with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) are at high risk for impaired antiplatelet activity secondary to malabsorption, systemic hypoperfusion, hypothermia, need for mechanical ventilation, and high use of analgesics. The use of antiplatelet therapy in these high-risk patients is not well studied. METHODS Using the National Cardiogenic Shock Initiative database, we analyzed patients who presented with AMI-CS at 60 hospitals from March 2018 to December 2020. All patients were treated using a standard shock protocol. Herein, the patterns of antiplatelet use are described. RESULTS A total of 204 patients were included in the analysis, of which 174 (85.3%) presented with ST-segment elevation myocardial infarction (STEMI). The majority (84.3%) received antiplatelet therapy before percutaneous coronary intervention (PCI); of those who received antiplatelets, 77.9% received aspirin, 55.2% received an oral P2Y12 inhibitor, and 19.2% received intravenous (IV) antiplatelet therapy. Ticagrelor was the most common P2Y12 inhibitor administered (41.9%), followed by clopidogrel (12.2%) and prasugrel (1.2%). Only 18.6% of oral antiplatelet agents were crushed. Baseline characteristics of patients who received IV vs non-IV antiplatelet agents were similar. Thrombolysis in Myocardial Infarction (TIMI) 0 flow was present in 69.6% of patients before PCI and aspiration thrombectomy was performed in 24.5% of patients. The presence of STEMI, cardiac arrest, cardiopulmonary resuscitation, hypothermia, vasopressor use, elevated lactate levels, or number of vessels treated did not influence the use of IV antiplatelet agents. CONCLUSIONS The use of crushed and IV antiplatelet agents in AMI-CS is low. Further studies are needed in this high-risk population to assess whether more potent antiplatelet inhibition will improve outcomes.
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Affiliation(s)
- Sarah Gorgis
- Henry Ford Hospital, Cardiovascular Department, 2799 W Grand Blvd, Detroit, MI 48202 USA.
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Park KH, Jeong MH, Kim HK, Ki YJ, Kim SS, Ahn Y, Kook HY, Kim HS, Gwon HC, Seung KB, Rha SW, Chae SC, Kim CJ, Cha KS, Park JS, Yoon JH, Chae JK, Joo SJ, Choi DJ, Hur SH, Seong IW, Cho MC, Kim DI, Oh SK, Ahn TH, Hwang JY. The current status and outcomes of in-hospital P2Y12 receptor inhibitor switching in Korean patients with acute myocardial infarction. Korean J Intern Med 2022; 37:350-365. [PMID: 35016269 PMCID: PMC8925943 DOI: 10.3904/kjim.2021.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/31/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND/AIMS While switching strategies of P2Y12 receptor inhibitors (RIs) have sometimes been used in acute myocardial infarction (AMI) patients, the current status of in-hospital P2Y12RI switching remains unknown. METHODS Overall, 8,476 AMI patients who underwent successful revascularization from Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) were divided according to in-hospital P2Y12RI strategies, and net adverse cardiovascular events (NACEs), defined as a composite of cardiac death, non-fatal myocardial infarction (MI), stroke, or thrombolysis in myocardial infarction (TIMI) major bleeding during hospitalization were compared. RESULTS Patients with in-hospital P2Y12RI switching accounted for 16.5%, of which 867 patients were switched from clopidogrel to potent P2Y12RI (C-P) and 532 patients from potent P2Y12RI to clopidogrel (P-C). There were no differences in NACEs among the unchanged clopidogrel, the unchanged potent P2Y12RIs, and the P2Y12RI switching groups. However, compared to the unchanged clopidogrel group, the C-P group had a higher incidence of non-fatal MI, and the P-C group had a higher incidence of TIMI major bleeding. In clinical events of in-hospital P2Y12RI switching, 90.9% of non-fatal MI occurred during pre-switching clopidogrel administration, 60.7% of TIMI major bleeding was related to pre-switching P2Y12RIs, and 71.4% of TIMI major bleeding was related to potent P2Y12RIs. Only 21.6% of the P2Y12RI switching group switched to P2Y12RIs after a loading dose (LD); however, there were no differences in clinical events between patients with and without LD. CONCLUSION In-hospital P2Y12RI switching occurred occasionally, but had relatively similar clinical outcomes compared to unchanged P2Y12RIs in Korean AMI patients. Non-fatal MI and bleeding appeared to be mainly related to pre-switching P2Y12RIs.
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Affiliation(s)
- Keun-Ho Park
- Division of Cardiology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun Kuk Kim
- Division of Cardiology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Young-Jae Ki
- Division of Cardiology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Sung Soo Kim
- Division of Cardiology, Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun Yi Kook
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyeon Cheol Gwon
- Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Bae Seung
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Chong Jin Kim
- Cardiovascular Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kwang Soo Cha
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Jong Seon Park
- Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jung Han Yoon
- Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jei Keon Chae
- Department of Internal Medicine, Jeonbuk National University Hospital, Jeonju, Korea
| | - Seung Jae Joo
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Dong-Joo Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
| | - In Whan Seong
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Doo Il Kim
- Division of Cardiology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Seok Kyu Oh
- Division of Cardiology, Department of Internal Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Tae Hoon Ahn
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin Yong Hwang
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
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Wöhrle J, Seeger J, Lahu S, Mayer K, Bernlochner I, Gewalt S, Menichelli M, Witzenbichler B, Hochholzer W, Sibbing D, Cassese S, Angiolillo DJ, Hemetsberger R, Valina C, Kufner S, Xhepa E, Hapfelmeier A, Sager HB, Joner M, Richardt G, Laugwitz KL, Neumann FJ, Schunkert H, Schüpke S, Kastrati A, Ndrepepa G. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndrome in Relation to Estimated Glomerular Filtration Rate. JACC Cardiovasc Interv 2021; 14:1857-1866. [PMID: 34446390 DOI: 10.1016/j.jcin.2021.06.028] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to assess the safety and efficacy of ticagrelor versus prasugrel for patients with acute coronary syndrome (ACS) according to their estimated glomerular filtration rates (eGFRs). BACKGROUND The outcomes of ticagrelor versus prasugrel in patients with ACS according to eGFR have not been defined. METHODS Patients (n = 4,012) were categorized into 3 groups: low eGFR (<60 mL/min/1.73 m2), intermediate eGFR (≥60 and <90 mL/min/1.73 m2), and high eGFR (≥90 mL/min/1.73 m2). The primary endpoint was a composite of all-cause death, myocardial infarction, and stroke; the secondary safety endpoint was Bleeding Academic Research Consortium types 3 to 5 bleeding, both at 1 year. RESULTS Patients with low eGFRs had a higher risk for the primary endpoint compared with patients with intermediate eGFRs (adjusted HR: 1.89; 95% CI: 1.46-2.46]) and those with high eGFRs (adjusted HR: 2.33; 95% CI: 1.57-3.46). A risk excess for low eGFR was also observed for bleeding (adjusted HR: 1.55 [95% CI: 1.12-2.13] vs intermediate eGFR; adjusted HR: 1.59 [95% CI: 1.01-2.50] vs high eGFR). However, eGFR did not affect the relative efficacy and safety of ticagrelor versus prasugrel. In patients with low eGFR, the primary endpoint occurred in 20.5% with ticagrelor and in 14.7% with prasugrel (HR: 1.47; 95% CI: 1.04-2.08; P = 0.029); there was no significant difference in bleeding. CONCLUSIONS These results show that among patients with ACS, reduction of eGFR is associated with increased risk for ischemic and bleeding events but has no significant impact on the relative efficacy and safety of ticagrelor versus prasugrel. (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome [ISAR-REACT 5]; NCT01944800).
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Affiliation(s)
- Jochen Wöhrle
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany.
| | - Julia Seeger
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
| | - Shqipdona Lahu
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Katharina Mayer
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Senta Gewalt
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | | | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany; Klinik der Universität München, Ludwig-Maximilians-University, Cardiology, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
| | - Hendrik B Sager
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Franz Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Cardiology, and Technische Universität München, Munich, Germany
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Abusnina W, Al-Abdouh A, Bizanti A, Gill G, Houssien A, Alshebani Y, Kanmanthareddy A, Dahal K. Ischemic and bleeding outcomes of potent P2Y12 inhibitor antiplatelet agents versus clopidogrel in elderly patients with acute coronary syndrome: A meta-analysis of randomized trials. Cardiovasc Revasc Med 2021; 38:54-60. [PMID: 34384690 DOI: 10.1016/j.carrev.2021.08.008] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population. METHODS AND RESULTS PubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82-1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75-1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78-1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82-1.86]; p=0.31). However, potent oral P2Y12 inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68-0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09-1.59]; p<0.01). CONCLUSION In comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Ahmad Al-Abdouh
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD 21229, USA
| | - Anas Bizanti
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD 21229, USA
| | - Gauravpal Gill
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Abdelrazeg Houssien
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Yazeid Alshebani
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Arun Kanmanthareddy
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA
| | - Khagendra Dahal
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE 68124, USA.
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Satilmisoglu MH, Gul M, Ozyilmaz S, Cizgici AY. Real-life data for major adverse cardiac events in patients with ST-elevation myocardial infarction prasugrel versus ticagrelor. J Physiol Pharmacol 2021; 72. [PMID: 34987130 DOI: 10.26402/jpp.2021.4.08] [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] [Received: 06/28/2021] [Accepted: 08/30/2021] [Indexed: 06/14/2023]
Abstract
We aimed to evaluate the major adverse cardiac events and other clinical outcomes in ST-segment-elevation myocardial infarction (STEMI) cases treated with prasugrel versus ticagrelor after percutaneous intervention (PCI). The study was a prospective comparative study into which 560 patients diagnosed with STEMI, being suitable for PCI, and prescribed with either prasugrel (n = 232) or ticagrelor (n = 328) as oral antiplatelet therapy were included. Patients were followed up for a mean of 10.9 ± 4.7 months and 11.9 ± 4.9 months for prasugrel and ticagrelor groups, respectively. The major adverse cardiac events developed in similar rates between prasugrel and ticagrelor groups (7.3% versus 7.9%, respectively, p = 0.793). Even if mortality rate was higher in ticagrelor group, the difference did not reach statistically significance (3.4% vs. 6.7%, p=0.092). Among all study population, stent thrombosis and minor bleeding was recorded only in 7 (1.2%) and 12 (2.1%) patients without significant difference between prasugrel and ticagrelor groups. Twenty patients (8.6%) in prasugrel group and 47 patients (14.3%) in ticagrelor group discontinued treatment (p = 0.023). In ticagrelor group, 12 patients discontinued treatment due to dyspnea, but none in prasugrel group (p = 0.001). Prasugrel and ticagrelor have similar effects on major adverse cardiac events in patients with STEMI undergoing primary PCI, but prasugrel seems more tolerated and less discontinued than ticagrelor.
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Affiliation(s)
- M H Satilmisoglu
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
| | - M Gul
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - S Ozyilmaz
- Department of Cardiology, Medical Faculty of Istanbul Aydin University, VM Florya Medical Park Hospital, Istanbul, Turkey
| | - A Y Cizgici
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Otsuka T, Ueki Y, Kavaliauskaite R, Zanchin T, Bär S, Stortecky S, Pilgrim T, Valgimigli M, Meier B, Heg D, Windecker S, Räber L. Single antiplatelet therapy with use of prasugrel in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:E213-E221. [PMID: 33754441 DOI: 10.1002/ccd.29650] [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: 12/26/2020] [Revised: 02/04/2021] [Accepted: 03/12/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We aimed to assess the ischemic and bleeding risks of single antiplatelet therapy (SAPT) with prasugrel compared with standard dual antiplatelet therapy (DAPT) (aspirin plus clopidogrel for 1 year) in patients with chronic coronary syndrome (CCS) treated with new generation drug-eluting stents (DES). BACKGROUND To date, data on SAPT with potent P2Y12 inhibitors in the absence of aspirin immediately after PCI are limited. METHODS Between January 2009 and November 2019, all CCS patients undergoing percutaneous coronary intervention (PCI) enrolled to the Bern PCI registry were considered for analysis. We performed propensity score matching in a 1:4 fashion to compare patients who received SAPT with prasugrel versus standard DAPT. The primary ischemic endpoint was a composite of cardiovascular death, myocardial infarction, and stroke and the primary bleeding endpoint was BARC 3 or 5 bleeding, both assessed at 1 year. RESULTS After propensity score matching, the final study population consisted of 225 patients with SAPT and 889 with DAPT. There was no significant difference in rates of the primary ischemic (5.2% vs. 4.2%, p = .50) or the primary bleeding (1.5% vs. 2.0%, p = .60) endpoints between groups. SAPT was not associated with an increased risk of definite stent thrombosis (0.9% vs. 0.8%, p = .83). CONCLUSIONS Among selected CCS patients undergoing PCI with DES, SAPT with prasugrel was not associated with an excess of ischemic events compared with standard DAPT. No difference in bleeding was observed either. The results may serve as the basis for larger trials assessing the potential benefits and risks of SAPT.
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Affiliation(s)
- Tatsuhiko Otsuka
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasushi Ueki
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raminta Kavaliauskaite
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Zanchin
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sarah Bär
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dik Heg
- Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
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Orban M, Kleeberger J, Ouarrak T, Freund A, Feistritzer HJ, Fuernau G, Geisler T, Huber K, Dudek D, Noc M, Montalescot G, Neumer A, Haller P, Clemmensen P, Zeymer U, Desch S, Massberg S, Schneider S, Thiele H, Hausleiter J. Clopidogrel vs. prasugrel vs. ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis. Clin Res Cardiol 2021; 110:1493-1503. [PMID: 33999281 PMCID: PMC8405498 DOI: 10.1007/s00392-021-01866-3] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022]
Abstract
Aims The aim of this pooled sub-analysis of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated either with clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Methods and results For the current analysis the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. 856 patients were eligible for analysis. Of these, 507 patients (59.2%) received clopidogrel, 178 patients (20.8%) prasugrel and 171 patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ significantly between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj = 0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj = 0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20 -0.69, padj = 0.002) and not significantly different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43 -1.24, padj = 0.24). Conclusion This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that acute therapy with either clopidogrel, prasugrel or ticagrelor is no independent predictor of 1-year mortality. Treatment with ticagrelor seems independently associated with less in-hospital moderate and severe bleeding events compared to clopidogrel. This finding might be due to selection bias and should be interpreted with caution. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01866-3.
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Affiliation(s)
- Martin Orban
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany.
- Medizinische Klinik und Poliklinik I, LMU Klinikum München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Germany.
| | - Jan Kleeberger
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Taoufik Ouarrak
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | | | - Kurt Huber
- Medical Faculty, 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud University, Vienna, Austria
| | | | - Marko Noc
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Alexander Neumer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Paul Haller
- Universitäres Herz- Und Gefäßzentrum UKE Hamburg, Klinik Und Poliklinik Für Kardiologie, Hamburg, Germany
| | - Peter Clemmensen
- Universitäres Herz- Und Gefäßzentrum UKE Hamburg, Klinik Und Poliklinik Für Kardiologie, Hamburg, Germany
| | - Uwe Zeymer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
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Soueid AE, Kassas I, Rade J, Kakouros N. Evaluation of a Real-World In-Hospital Antiplatelet-Switching Strategy Following Coronary Interventions: The SWITCH Study. J Invasive Cardiol 2021; 33:E263-E268. [PMID: 33794478] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Antiplatelet therapy is paramount to reduce the risk of coronary stent thrombosis after percutaneous coronary intervention (PCI). Newer agents are reliable and have a fast onset of action, but have significantly higher cost, leading to compliance concerns. We adopted and evaluated an acute agent-switching strategy, using prasugrel or ticagrelor for rapid and reliable periprocedural antiplatelet action, followed by a switch to generic clopidogrel. METHODS This large, single-center study included all patients who underwent PCI between January 1, 2013 and December 31, 2016. Study endpoints were 30- day mortality and bleeding events. RESULTS A total of 5007 patients met inclusion criteria. Average age was 63.5 ± 12.5 years. Prior to PCI, 54.8% of patients were preloaded with ticagrelor, 8.5% with prasugrel, and 36.7% with clopidogreI. The majority of patients (93%) loaded with ticagrelor and more than half (58%) of those loaded with prasugrel were subsequently switched prior to hospital discharge to clopidogrel for long-term therapy. Patients pretreated with ticagrelor or prasugrel and switched to clopidogrel had overall lowest bleeding rates (0.9% and 0.8%, respectively). The highest rates of bleeding were noted in patients maintained on ticagrelor or clopidogrel throughout (2.5% and 1.7%, respectively). After accounting for additional periprocedural use of intravenous glycoprotein IIb/IIIa inhibitors, the lowest bleeding rates were observed in patients loaded with ticagrelor and switched to clopidogrel (0.75%), with the highest bleeding observed in patients maintained on ticagrelor throughout. There were no events of acute stent thrombosis. CONCLUSIONS A strategy of using newer, fast-acting, and reliable antiplatelet agents prior to PCI and acutely switching to long-term clopidogrel therapy appears safe and efficacious. Although the superiority of the newer antiplatelet agents for long-term post-PCI dual-antiplatelet therapy in a trial setting is well established, the impact of increased adherence to lower-cost clopidogrel therapy in the real-world setting merits further consideration.
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Affiliation(s)
| | | | | | - Nikolaos Kakouros
- UMass Memorial Medical Center, Cardiovascular Medicine, 55 Lake Avenue North, Worcester, MA 01655 USA.
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Danek BA, Karatasakis A, Abdullah K, Iwnetu R, Kalsaria P, Shunk K, Zimmet J, Vidovich M, Bavry AA, Rangan BV, Roesle M, Griza D, Stanley K, Banerjee S, Khalili H, Brilakis ES, Abdullah SM. A Randomized Controlled Trial of Prasugrel for Prevention of Early Saphenous Vein Graft Thrombosis. J Invasive Cardiol 2020; 32:E305-E312. [PMID: 32961528] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To test whether administration of prasugrel after coronary artery bypass grafting (CABG) reduces saphenous vein graft (SVG) thrombosis. Use of aspirin after CABG improves graft patency, but administration of other antiplatelet agents has yielded equivocal results. METHODS We performed a double-blind trial randomizing patients to prasugrel or placebo after CABG at four United States centers. Almost all patients were receiving aspirin. Follow-up angiography, optical coherence tomography (OCT), intravascular ultrasound (IVUS), and near-infrared spectroscopy (NIRS) were performed at 12 months. The primary efficacy endpoint was prevalence of OCT-detected SVG thrombus. The primary safety endpoint was incidence of Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) severe bleeding. RESULTS The study was stopped early due to slow enrollment after randomizing 84 patients. Mean age was 64 ± 6 years; 98% of the patients were men. Follow-up angiography was performed in 59 patients. IVUS was performed in 52 patients, OCT in 53 patients, and NIRS in 33 patients. Thrombus was identified by OCT in 56% vs 50% of patients in the prasugrel vs placebo groups, respectively (P=.78). Angiographic SVG failure occurred in 24% of patients in the prasugrel arm vs 40% in the placebo arm (P=.19). The 1-year incidence of major adverse cardiovascular events was 14.3% vs 2.4% in the prasugrel and placebo groups, respectively (P=.20), without significant differences in GUSTO severe bleeding (P=.32). CONCLUSION Early SVG failure occurred in approximately one-third of patients. Prasugrel did not decrease prevalence of SVG thrombus 12 months after CABG.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Shuaib M Abdullah
- Shuaib Abdullah, MD, Veterans Affairs North Texas Health Care System, 4500 South Lancaster, 111A, Dallas, TX 75216 USA.
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Kim HS, Kang J, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Rhew JY, Chun KJ, Lim YH, Bong JM, Bae JW, Lee BK, Park KW. Prasugrel-based de-escalation of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (HOST-REDUCE-POLYTECH-ACS): an open-label, multicentre, non-inferiority randomised trial. Lancet 2020; 396:1079-1089. [PMID: 32882163 DOI: 10.1016/s0140-6736(20)31791-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [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: 07/30/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND A potent P2Y12 inhibitor-based dual antiplatelet therapy is recommended for up to 1 year in patients with acute coronary syndrome receiving percutaneous coronary intervention (PCI). The greatest benefit of the potent agent is during the early phase, whereas the risk of excess bleeding continues in the chronic maintenance phase. Therefore, de-escalation of antiplatelet therapy might achieve an optimal balance between ischaemia and bleeding. We aimed to investigate the safety and efficacy of a prasugrel-based dose de-escalation therapy. METHODS HOST-REDUCE-POLYTECH-ACS is a randomised, open-label, multicentre, non-inferiority trial done at 35 hospitals in South Korea. We enrolled patients with acute coronary syndrome receiving PCI. Patients meeting the core indication for prasugrel were randomly assigned (1:1) to the de-escalation group or conventional group using a web-based randomisation system. The assessors were masked to the treatment allocation. After 1 month of treatment with 10 mg prasugrel plus 100 mg aspirin daily, the de-escalation group received 5 mg prasugrel, while the conventional group continued to receive 10 mg. The primary endpoint was net adverse clinical events (all-cause death, non-fatal myocardial infarction, stent thrombosis, repeat revascularisation, stroke, and bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria) at 1 year. The absolute non-inferiority margin for the primary endpoint was 2·5%. The key secondary endpoints were efficacy outcomes (cardiovascular death, myocardial infarction, stent thrombosis, and ischaemic stroke) and safety outcomes (bleeding events of BARC grade ≥2). The primary analysis was in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02193971. RESULTS From Sept 30, 2014, to Dec 18, 2018, 3429 patients were screened, of whom 1075 patients did not meet the core indication for prasugrel and 16 were excluded due to randomisation error. 2338 patients were randomly assigned to the de-escalation group (n=1170) or the conventional group (n=1168). The primary endpoint occurred in 82 patients (Kaplan-Meier estimate 7·2%) in the de-escalation group and 116 patients (10·1%) in the conventional group (absolute risk difference -2·9%, pnon-inferiority<0·0001; hazard ratio 0·70 [95% CI 0·52-0·92], pequivalence=0·012). There was no increase in ischaemic risk in the de-escalation group compared with the conventional group (0·76 [0·40-1·45]; p=0·40), and the risk of bleeding events was significantly decreased (0·48 [0·32-0·73]; p=0·0007). INTERPRETATION In east Asian patients with acute coronary syndrome patients receiving PCI, a prasugrel-based dose de-escalation strategy from 1 month after PCI reduced the risk of net clinical outcomes up to 1 year, mainly driven by a reduction in bleeding without an increase in ischaemia. FUNDING Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio.
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Affiliation(s)
- Hyo-Soo Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul, South Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul, South Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul, South Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul, South Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, South Korea
| | | | - Kook-Jin Chun
- Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Young-Hyo Lim
- Hanyang University Seoul Hospital, Seoul, South Korea
| | | | | | - Bong Ki Lee
- Kangwon National University, Chuncheon, South Korea
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Ishida M, Takahashi F, Goto I, Niiyama M, Saitoh H, Sakamoto T, Maegawa Y, Osaki T, Nishiyama O, Endo H, Sakamoto R, Kojima T, Koeda Y, Kimura T, Itoh T, Morino Y. Clinical outcomes of patients treated using very short duration dual antiplatelet therapy after implantation of biodegradable-polymer drug-eluting stents: rationale and design of a prospective multicenter REIWA registry. Cardiovasc Interv Ther 2020; 35:398-404. [PMID: 32776221 DOI: 10.1007/s12928-020-00694-y] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/02/2020] [Indexed: 12/22/2022]
Abstract
Several studies have demonstrated the safety and feasibility of short (3-6 months) and very short duration (< 2 months) dual antiplatelet therapy (DAPT) in patients with a durable-polymer drug-eluting stent (DP-DES). However, the clinical importance of using very short duration DAPT has yet to be established in patients with a biodegradable polymer drug-eluting stent (BP-DES). The aim of this REIWA registry (multicenter and prospective registry; investigation of clinical outcomes of patients treated with short duration dual antiplatelet therapy after implantation of biodresorbable-polymer drug-eluting stent: a multicenter, prospective registry from Iwate medical university affiliated hospitals) is to determine the safety and feasibility of using 1-month DAPT followed by P2Y12 inhibitor monotherapy in patients after BP-DES implantation. This study is an observational, prospective, multicenter registry encompassing the entire local medical region of Iwate Prefecture (northern area of mainland Japan). A total of 1200 patients who underwent successful PCI with a novel thin strut BP-DES (Synergy, Ultimaster or Orsiro) and are considered to be appropriate patients for very short DAPT, are registered and subsequently administered 1-month DAPT followed by P2Y12 inhibitor monotherapy (clopidogrel 75 mg/day or prasugrel 3.75 mg/day). The primary endpoint was a composite of cardiovascular and bleeding events, which included cardiovascular death, spontaneous myocardial infarction, definite stent thrombosis, ischemic or hemorrhagic stroke, or TIMI major or minor bleeding at 12 months. The REIWA registry (UMIN000037321) will demonstrate both the safety and feasibility of using 1-month DAPT in patients with BP-DES. Furthermore, results of this study will also be able to provide supportive evidence for P2Y12 inhibitor monotherapy after 1-month DAPT following BP-DES implantation.
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Affiliation(s)
- Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 020-3695, Japan.
| | - Fumiaki Takahashi
- Division of Medical Engineering, Department of Information Science, Iwate Medical University, Yahaba-cho, Iwate, Japan
| | - Iwao Goto
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 020-3695, Japan
| | - Masanobu Niiyama
- Department of Cardiology, Hachinohe Red Cross Hospital, Hachinohe, Japan
| | - Hidenori Saitoh
- Department of Cardiology, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Tsubasa Sakamoto
- Department of Cardiology, Iwate Prefectural Ofunato Hospital, Ofunato, Japan
| | - Yuko Maegawa
- Department of Cardiology, Iwate Prefectural Miyako Hospital, Miyako, Japan
| | - Takuya Osaki
- Department of Cardiology, Iwate Prefectural Kuji Hospital, Kuji, Japan
| | - Osamu Nishiyama
- Department of Cardiology, Iwate Prefectural Ninohe Hospital, Ninohe, Japan
| | - Hiroshi Endo
- Department of Cardiology, Iwate Prefectural Iwai Hospital, Ichinoseki, Japan
| | - Ryohei Sakamoto
- Department of Cardiology, Nakadori General Hospital, Akita, Japan
| | - Tsuyoshi Kojima
- Department of Cardiology, Morioka Red Cross Hospital, Morioka, Japan
| | - Yorihiko Koeda
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 020-3695, Japan
| | - Takumi Kimura
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 020-3695, Japan
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 020-3695, Japan
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 020-3695, Japan
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Zekery-Saad SA, Lewin A, Pham M, Sylvester KW, Fanikos J, Goldhaber SZ, Connors JM. Evaluation and optimization of prescribed concomitant antiplatelet and anticoagulation therapy centrally managed by an anticoagulation management service. J Thromb Thrombolysis 2020; 51:405-412. [PMID: 32651889 DOI: 10.1007/s11239-020-02207-3] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients on long-term anticoagulation combined with antiplatelet therapy have an increased risk of bleeding compared to patients on anticoagulation alone. The aim of this study was to evaluate the appropriateness of antiplatelet therapy in patients who are on long-term warfarin therapy and are managed by Brigham and Women's Hospital Anticoagulation Management Service (BWH AMS). This was a single-center, prospective chart review of patients managed by BWH AMS who were on long-term warfarin therapy plus full-dose aspirin (325 mg), an oral P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) and/or acetylsalicylic acid/dipyridamole. Patients' cardiovascular (CV) benefit and risk of bleeding were assessed according to clinical guidelines. The major objective of the study was to determine the proportion of patients on dual antithrombotic therapy (DAT) or triple antithrombotic therapy (TAT) whose risk of bleeding outweighed CV benefit. Of the 2677 patients evaluated for inclusion,145 were on concomitant long-term warfarin therapy plus aspirin (325 mg), an oral P2Y12 inhibitor and/or acetylsalicylic acid/dipyridamole. A total of 85 patients (58.6%) had no clear indication for DAT or TAT per guideline recommendations and were categorized as bleeding risk outweighing CV benefit. The remaining 60 patients (41.4%) had an appropriate indication for DAT or TAT per guidelines and were categorized as CV benefit outweighing bleeding risk. BWH AMS pharmacists made 33 (22.9%) recommendations to providers to discontinue or de-escalate antiplatelet therapy. Interventions were accepted for 10 (30.3%) patients. Pharmacist involvement in the management of patients' antithrombotic regimens can optimize guideline-directed medical therapy and mitigate the potential risk of bleeding.
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Affiliation(s)
- Sara A Zekery-Saad
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
| | - Andrea Lewin
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Magie Pham
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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De Luca G, Verdoia M, Savonitto S, Ferri LA, Piatti L, Grosseto D, Morici N, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Ferrario M, Murena E, Sibilio G, Tondi S, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Antonicelli R, Rogacka R, De Servi S. Impact of body mass index on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: Insights from the ELDERLY ACS 2 trial. Nutr Metab Cardiovasc Dis 2020; 30:730-737. [PMID: 32127336 DOI: 10.1016/j.numecd.2020.01.001] [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: 08/07/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIM Elderly patients are at increased risk of hemorrhagic and thrombotic complications after an acute coronary syndrome (ACS). Frailty, comorbidities and low body weight have emerged as conditioning the prognostic impact of dual antiplatelet therapy (DAPT). The aim of the present study was to investigate the prognostic impact of body mass index (BMI) on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study comparing low-dose (5 mg) prasugrel vs clopidogrel among elderly patients with ACS. METHODS AND RESULTS Our population is represented by 1408 patients enrolled in the Elderly-ACS 2 trial. BMI was calculated at admission. The primary endpoint of this analysis was cardiovascular (CV) mortality. Secondary endpoints were all-cause death, recurrent MI, Bleeding Academic Research Consortium (BARC) type 2 or 3 bleeding, and re-hospitalization for cardiovascular reasons or stent thrombosis within 12 months after index admission. Patients were grouped according to median values of BMI (<or ≥ 25.7 kg/m2). BMI was associated with hypertension, diabetes, hypercholesterolemia, estimated glomerular filtration rate and hemoglobin (p < 0.001), and inversely with age (p = 0.005). Overweight patients displayed larger use of diuretics at admission (p = 0.03), aspirin pre-randomization (p = 0.01) and radial access (p = 0.04). At a median follow-up of 367 [337-378] days, BMI did not affect CV mortality in the overall population 4% vs 3.8%; adjusted HR [95%CI] = 2.3 [0.8-6.5], p = 0.12. Similar findings were observed for our secondary efficacy and safety endpoints. Results did not change when considering separately higher risk subsets of patients, (female gender, diabetics, ST-segment elevation myocardial infarction or the type of DAPT treatment allocation), with no significant interaction between these population characteristics and BMI. CONCLUSIONS Among elderly patients with ACS, BMI did not condition the survival or the risk of major cardiovascular and bleeding complications. The results were consistent across several patient risk categories.
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Affiliation(s)
- Giuseppe De Luca
- Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
| | - Monica Verdoia
- Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | | | | | | | - Nuccia Morici
- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Irene Bossi
- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | | | | | | | | | | | | | | | | | | | - Elena Corrada
- HumanitasClinical and Research Center, Rozzano, Italy
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Gimbel M, Qaderdan K, Willemsen L, Hermanides R, Bergmeijer T, de Vrey E, Heestermans T, Tjon Joe Gin M, Waalewijn R, Hofma S, den Hartog F, Jukema W, von Birgelen C, Voskuil M, Kelder J, Deneer V, Ten Berg J. Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): the randomised, open-label, non-inferiority trial. Lancet 2020; 395:1374-1381. [PMID: 32334703 DOI: 10.1016/s0140-6736(20)30325-1] [Citation(s) in RCA: 184] [Impact Index Per Article: 46.0] [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: 01/05/2020] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines recommend potent platelet inhibition with ticagrelor or prasugrel in patients after an acute coronary syndrome. However, data about optimal platelet inhibition in older patients are scarce. We aimed to investigate the safety and efficacy of clopidogrel compared with ticagrelor or prasugrel in older patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS We did the open-label, randomised controlled POPular AGE trial in 12 sites (ten hospitals and two university hospitals) in the Netherlands. Patients aged 70 years or older with NSTE-ACS were enrolled and randomly assigned in a 1:1 ratio using an internet-based randomisation procedure with block sizes of six to receive a loading dose of clopidogrel 300 mg or 600 mg, or ticagrelor 180 mg or prasugrel 60 mg, and then a maintenance dose for the duration of 12 months (clopidogrel 75 mg once daily, ticagrelor 90 mg twice daily, or prasugrel 10 mg once daily) on top of standard care. Patient and treating physicians were aware of the allocated treatment strategy, but the outcome assessors were masked to treatment allocation. Primary bleeding outcome consisted of PLATelet inhibition and patient Outcomes (PLATO; major or minor bleeding [superiority hypothesis]). Co-primary net clinical benefit outcome consisted of all-cause death, myocardial infarction, stroke, PLATO major and minor bleeding (non-inferiority hypothesis, margin of 2%). Follow-up duration was 12 months. Analyses were done on intention-to-treat basis. This trial is registered with the Netherlands Trial Register (NL3804), ClinicalTrials.gov (NCT02317198), and EudraCT (2013-001403-37). FINDINGS Between June 10, 2013, and Oct 17, 2018, 1002 patients were randomly assigned to clopidogrel (n=500) or ticagrelor or prasugrel (n=502). Because 475 (95%) patients received ticagrelor in the ticagrelor or prasugrel group, we will refer to this group as the ticagrelor group. Premature discontinuation of the study drug occurred in 238 (47%) of 502 ticagrelor group patients randomly assigned to ticagrelor, and in 112 (22%) of 500 patients randomly assigned to clopidogrel. Primary bleeding outcome was significantly lower in the clopidogrel group (88 [18%] of 500 patients) than in the ticagrelor group (118 [24%] of 502; hazard ratio 0·71, 95% CI 0·54 to 0·94; p=0·02 for superiority). Co-primary net clinical benefit outcome was non-inferior for the use of clopidogrel (139 [28%]) versus ticagrelor (161 [32%]; absolute risk difference -4%, 95% CI -10·0 to 1·4; p=0·03 for non-inferiority). The most important reasons for discontinuation were occurrence of bleeding (n=38), dyspnoea (n=40), and the need for treatment with oral anticoagulation (n=35). INTERPRETATION In patients aged 70 years or older presenting with NSTE-ACS, clopidogrel is a favourable alternative to ticagrelor, because it leads to fewer bleeding events without an increase in the combined endpoint of all-cause death, myocardial infarction, stroke, and bleeding. Clopidogrel could be an alternative P2Y12 inhibitor especially for elderly patients with a higher bleeding risk. FUNDING ZonMw.
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Affiliation(s)
- Marieke Gimbel
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Khalid Qaderdan
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Laura Willemsen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Rik Hermanides
- Department of Cardiology, Isala Hospitals, Zwolle, Netherlands
| | - Thomas Bergmeijer
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Evelyn de Vrey
- Department of Cardiology, Meander Medical Centre, Amersfoort, Netherlands
| | - Ton Heestermans
- Department of Cardiology, Noord-west Hospital group, Alkmaar, Netherlands
| | | | | | - Sjoerd Hofma
- Department of Cardiology, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | - Frank den Hartog
- Department of Cardiology, Gelderse Vallei Hospital, Ede, Netherlands
| | - Wouter Jukema
- Department of Cardiology, Leids University Medical Centre, Leiden, Netherlands
| | | | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Johannes Kelder
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Vera Deneer
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands; Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics University Medical Center Utrecht and Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands.
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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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Shoji S, Sawano M, Sandhu AT, Heidenreich PA, Shiraishi Y, Ikemura N, Ueno K, Suzuki M, Numasawa Y, Fukuda K, Kohsaka S. Ischemic and Bleeding Events Among Patients With Acute Coronary Syndrome Associated With Low-Dose Prasugrel vs Standard-Dose Clopidogrel Treatment. JAMA Netw Open 2020; 3:e202004. [PMID: 32239221 PMCID: PMC7118520 DOI: 10.1001/jamanetworkopen.2020.2004] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Prasugrel was approved at a lower dose in 2014 in Japan than in the West because East Asian patients are considered more susceptible to bleeding than Western patients. However, real-world outcomes with low-dose prasugrel treatment remain unclear. OBJECTIVE To investigate the association of low-dose prasugrel vs standard-dose clopidogrel administration with short-term outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). DESIGN, SETTING, AND PARTICIPANTS This study used data from the Japan Cardiovascular Database-Keio Interhospital Cardiovascular Studies registry, a large, ongoing, multicenter, retrospective cohort of consecutive patients who underwent PCI. The present cohort study evaluated 2770 patients with acute coronary syndrome who underwent PCI and received either low-dose prasugrel (loading dose, 20 mg; maintenance dose, 3.75 mg) or clopidogrel (loading dose, 300 mg; maintenance dose, 75 mg) in combination with aspirin between 2014 and 2018. Propensity score-matching analysis was conducted to balance the baseline characteristics of patients receiving low-dose prasugrel and those receiving clopidogrel. Data analysis was conducted in June 2019. EXPOSURES Prescription of either low-dose prasugrel or standard-dose clopidogrel prior to PCI. MAIN OUTCOMES AND MEASURES Primary ischemic events (in-hospital death, recurrent myocardial infarction, and ischemic stroke) and primary bleeding events, defined as bleeding complications within 72 hours after PCI consistent with the National Cardiovascular Data Registry CathPCI Registry definition. RESULTS Of 2559 patients included in the study, the mean (SD) age was 67.8 (12.7) years, and 78.2% were male. In total, 1297 patients (50.7%) received low-dose prasugrel, and 1262 patients (49.3%) received clopidogrel. After propensity score matching, primary ischemic events among patients receiving low-dose prasugrel and those receiving clopidogrel were comparable (odds ratio [OR], 1.42; 95% CI, 0.90-2.23), but primary bleeding events were significantly higher among patients receiving prasugrel (OR, 2.91; 95% CI, 1.63-5.18). This increase in bleeding events was associated with the presence of a profile of high-bleeding risk (≥75 years of age, body weight <60 kg, or history of stroke or transient ischemic attack) (OR, 4.08; 95% CI, 1.86-8.97), being female (OR, 3.84; 95% CI, 1.05-14.0), or the presence of ST-segment elevation myocardial infarction (OR, 2.07; 95% CI, 1.05-4.09) or chronic kidney disease (OR, 4.78; 95% CI, 1.95-11.7). CONCLUSIONS AND RELEVANCE Since its approval, low-dose prasugrel has been used by nearly 80% of patients who undergo PCI. Despite the modified dose, bleeding events were higher among patients receiving low-dose prasugrel than among patients receiving clopidogrel, with no difference in ischemic events between the 2 groups. These results suggest the importance of a risk assessment of bleeding prior to selecting a P2Y12 inhibitor, even for the use of a lower approved dose, when treating patients of East Asian descent.
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Affiliation(s)
- Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Alexander T. Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
- Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Ikemura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Koji Ueno
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan
| | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization Saitama Hospital, Wako, Saitama, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Tochigi, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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