scholarly journals Stent thrombosis associated with newer P2Y12 inhibitors (ticagrelor & pasugrel) in a STEMI patient

2019 ◽  
Vol 3 (1) ◽  
pp. 26-30
Author(s):  
Mohammed Al Jarallah ◽  
Rajesh Rajan ◽  
Raja Dashti ◽  
Vladimir Kotevski ◽  
Nader Alasousi ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Stemi Patient ◽  
P2y12 Inhibitors

Relationship between degree of heparin anticoagulation and clinical outcome in patients receiving potent P2Y12-inhibitors with no planned glycoprotein IIb/IIIa inhibitor during percutaneous coronary intervention in acute myocardial infarction: a VALIDATE-SWEDEHEART substudy

2019 ◽  
Vol 6 (1) ◽  
pp. 6-13 ◽  
Author(s):  
Tania Sharma ◽  
Rebecca Rylance ◽  
Sofia Karlsson ◽  
Sasha Koul ◽  
Dimitrios Venetsanos ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Percutaneous Coronary Intervention ◽  
Stent Thrombosis ◽  
Composite Endpoint ◽  
Coronary Intervention ◽  
Heparin Dose ◽  
P2y12 Inhibitors ◽  
Percutaneous Coronary ◽  
The Individual

Abstract Aims Heparin is the preferred choice of anticoagulant in percutaneous coronary intervention (PCI) for acute myocardial infarction (MI). An established dosage of heparin has not yet been determined, but treatment may be optimized through monitoring of activated clotting time (ACT). The aim of this study was to determine the relationship between heparin dose or ACT with a composite outcome of death, MI, or bleeding using data from the registry-based, randomized, controlled, and open-label VALIDATE-SWEDEHEART trial, although patients were not randomized to heparin dose in this substudy. Methods and results Patients with MI undergoing PCI and receiving treatment with a potent P2Y12-inhibitor and anticoagulation with heparin, without the planned use of glycoprotein IIb/IIIa inhibitor (GPI), were enrolled in this substudy. The primary endpoint was a composite endpoint of death, MI, and bleeding at 30 days. The individual components and stent thrombosis were analysed separately. We divided patients into groups according to the initial dose of unfractionated heparin during PCI (<70 U/kg, 70–100 U/kg, and >100 U/kg) or ACT (ACT <250 s, 250–350 s, and >350 s) as well as investigating them as continuous variables in Cox proportional hazards models using univariable and multivariable analyses. No major differences were noted between heparin stratified in groups (P = 0.22) or heparin as a continuous variable in relation to the primary composite endpoint hazard ratio (HR) 1.0 confidence interval (CI) (0.99–1.01) for heparin dose/kg. No differences were found between ACT stratified in groups (P = 0.453) or ACT in seconds HR 1.0 CI (0.99–1.00) regarding the primary endpoint. The individual components of death, MI, major bleeding, and stent thrombosis were not significantly different across heparin doses or ACT levels either. Conclusion We found no association between heparin dose or ACT levels and death, MI bleeding complications, or stent thrombosis. Therefore, there is no strong support for a specific heparin dose or mandatory ACT monitoring in patients treated with potent P2Y12-inhibitors with no planned GPI.

scholarly journals Incidence and Clinical Features of Early Stent Thrombosis in the Era of New P2y12 Inhibitors (PLATIS-2)

PLoS ONE ◽  
2016 ◽  
Vol 11 (6) ◽  
pp. e0157437 ◽  
Author(s):  
Elad Asher ◽  
Arsalan Abu-Much ◽  
Ilan Goldenberg ◽  
Amit Segev ◽  
Avi Sabbag ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Clinical Features ◽  
P2y12 Inhibitors

Abstract 20470: Lower Mortality and Stent Thrombosis Rates Associated With Introduction of Potent P2Y12 Inhibitors in Patients With Acute Coronary Syndromes

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Javaid Iqbal ◽  
Rebecca Rowe ◽  
Yao-Jun Zhang ◽  
Yasir Parviz ◽  
Allison C Morton ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Acute Coronary Syndromes ◽  
Lower Mortality ◽  
Rank Test ◽  
P2y12 Inhibitors ◽  
Log Rank Test ◽  
Kaplan Meier ◽  
Confounding Variables ◽  
Coronary Syndromes ◽  
The Impact

Aims: We investigated the impact of new platelet P2Y12 inhibitors, prasugrel and ticagrelor, compared with clopidogrel, upon mortality and stent thrombosis (ST) in patients with acute coronary syndromes (ACS) in a large, single-centre, ‘all-comers’ population. Methods: Data were collected for 6742 consecutive patients attending the cardiac catheterization lab at Sheffield, UK (2009-2013) with ACS. Differences in outcomes among patients receiving different P2Y12 inhibitors were evaluated at 12 months by Kaplan-Meier curves and log-rank test in the overall and a propensity-matched population. Results: Of 6742 patients with ACS (36% STEMI, 64% NSTE-ACS), 67% (4525) received clopidogrel, 15% (1007) prasugrel and 18% (1210) ticagrelor, with aspirin for all. In the overall group, prasugrel (HR 0.78, 95% CI 0.59-1.02, p=0.07) and ticagrelor (HR 0.77, 95% CI 0.60-0.99, p=0.04) were associated with lower all-cause mortality compared with clopidogrel (Fig 1A). There was no difference in mortality between prasugrel- and ticagrelor-treated groups (HR 1.01, 95% CI 1.00-1.67, p=0.96). The incidence of definite/probable ST was 4.2% (1.5% definite, 2.7% probable) at 12 months. ST rates were nearly 2-fold higher in patients treated with either clopidogrel or prasugrel compared with ticagrelor (Fig 1B). In the STEMI subgroup, lower mortality and ST rates were observed with new P2Y12 inhibitors but no significant differences between prasugrel and ticagrelor (Fig 1C and 1D). The results for all ACS population or STEMI subgroup remained similar after adjustment for confounding variables or analysing propensity-matched cohorts. Conclusions: Both prasugrel and ticagrelor appear superior to clopidogrel for reduction in mortality in ACS in the ‘real world’. Ticagrelor was associated with the lowest mortality and ST rates in all ACS patients, whereas either prasugrel or ticagrelor appear suitable in STEMI patients without contraindications.

scholarly journals Clinical Impact of Intraprocedural Stent Thrombosis During Percutaneous Coronary Intervention in Patients Treated With Potent P2Y12 inhibitors ‐ a VALIDATE‐SWEDEHEART Substudy

2021 ◽  
Author(s):  
Sofia Bergman ◽  
Moman A. Mohammad ◽  
Stefan K. James ◽  
Oskar Angerås ◽  
Henrik Wagner ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Percutaneous Coronary Intervention ◽  
Stent Thrombosis ◽  
Coronary Intervention ◽  
Cardiovascular Death ◽  
St Segment Elevation ◽  
P2y12 Inhibitors ◽  
End Point ◽  
St Segment ◽  
Percutaneous Coronary

Background The clinical importance of intraprocedural stent thrombosis (IPST) during percutaneous coronary intervention in the contemporary era of potent oral P2Y12 inhibitors is not established. The aim of this study was to assess IPST and its association with clinical outcome in patients with myocardial infarction undergoing percutaneous coronary intervention with contemporary antithromboticmedications. Methods and Results The VALIDATE‐SWEDEHEART study (Bivalirudin Versus Heparin in ST‐Segment and Non–ST‐Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial) included 6006 patients with myocardial infarction, treated with potent P2Y12 inhibitors during percutaneous coronary intervention. IPST, defined as a new or worsening thrombus related to a stent deployed during the procedure, was reported by the interventional cardiologist in 55 patients (0.9%) and was significantly associated with ST‐segment elevation myocardial infarction presentation, longer stents, bailout glycoprotein IIb/IIIa inhibitors, and final Thrombolysis in Myocardial Infarction flow <3. The primary composite end point included cardiovascular death, myocardial infarction, out‐of‐laboratory definite stent thrombosis and target vessel revascularization within 30 days. Secondary end points were major bleeding and the individual components of the primary composite end point. Patients with versus without IPST had significantly higher rates of the primary composite end point (20.0% versus 4.4%), including higher rates of cardiovascular death, target vessel revascularization, and definite stent thrombosis, but not myocardial infarction or major bleeding. By multivariable analysis, IPST was independently associated with the primary composite end point (hazard ratio, 3.82; 95% CI, 2.05–7.12; P <0.001). Conclusions IPST is a rare but dangerous complication during percutaneous coronary intervention, independently associated with poor prognosis, even in the current era of potent antiplatelet agents. Future treatment studies are needed to reduce the rate of IPST and to improve the poor outcome among these patients. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02311231.

Optimal P2Y12 inhibition in older adults with acute coronary syndromes: a network meta-analysis of randomized controlled trials

2020 ◽  
Author(s):  
Claudio Montalto ◽  
Nuccia Morici ◽  
Andrea Raffaele Munafò ◽  
Antonio Mangieri ◽  
Alessandro Mandurino-Mirizzi ◽  
...  
Keyword(s):  
Older Adults ◽  
Stent Thrombosis ◽  
Primary Endpoint ◽  
Acute Coronary Syndromes ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
P2y12 Inhibitors ◽  
Fixed Proportion ◽  
Coronary Syndromes

Abstract Aims Dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor on top of aspirin is the cornerstone of therapy after acute coronary syndromes (ACS). Nonetheless, the safest and most efficacious P2Y12 for older patients who are both at high ischaemic and bleeding risk remains uncertain. We aimed to examine the effect of available P2Y12 inhibitors on ischaemic and bleeding endpoints in older adults with ACS. Methods and results Randomized clinical trials that reported separately the results of adults older &gt;70 years for at least the primary endpoint [composite of death, myocardial infarction (MI), and stroke]. Seven studies (14 485 patients-years) were included. Network meta-analysis showed that prasugrel was associated with similar occurrence of the primary endpoint and of a secondary ischaemic endpoint (composite of MI and stroke) and was most likely the best treatment [Surface Under the Cumulative Ranking curve Analysis (SUCRA) 54.5 and 59.8, respectively]. With regards to major bleedings, clopidogrel showed the highest likelihood of event reduction (SUCRA 70.1%), while ticagrelor of stent thrombosis (SUCRA 55.6%). Our meta-regression with a fixed proportion of patients managed invasively of 100% confirmed these trends with increasing SUCRA. Conclusion Among older subjects with ACS, DAPT should be balanced upon ischaemic and bleeding risks as prasugrel is associated with the highest probability of reduction of ischaemic events and clopidogrel of bleedings. Ticagrelor had highest SUCRA for stent thrombosis reduction but seems suboptimal in older adults.

scholarly journals Towards Personalized Medicine Based on Platelet Function Testing for Stent Thrombosis Patients

Thrombosis ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-11 ◽  
Author(s):  
Thea Cornelia Godschalk ◽  
Christian Marcus Hackeng ◽  
Jurriën Maria ten Berg
Keyword(s):  
Stent Thrombosis ◽  
Platelet Function ◽  
Platelet Reactivity ◽  
Variable Response ◽  
Cardiac Events ◽  
Bleeding Events ◽  
Platelet Function Testing ◽  
P2y12 Inhibitors ◽  
The One ◽  
Function Testing

Stent thrombosis (ST) is a severe and feared complication of coronary stenting. Patients who have suffered from ST are usually treated according to the “one-size-fits-all” dosing regimen of aspirin and clopidogrel. Many ST patients show high on-treatment platelet reactivity (HPR) despite this antiplatelet therapy (APT). It has been shown that HPR is a risk factor for major adverse cardiac events. Therefore, ST patients with HPR are at a high risk for recurrent atherothrombotic events. New insights into the variable response to clopidogrel and the advent of stronger P2Y12 inhibitors prasugrel and ticagrelor have changed the attention from a fixed APT treatment strategy towards “personalized APT strategies.” Strategies can be based on platelet function testing, which gives insight into the overall response of a patient to APT. At our outpatient ST clinic, we practice personalized APT based on platelet function testing to guide the cardiologist to a presumed optimal antiplatelet treatment of ST patients. Beside results of platelet function testing, comedication, clinical characteristics, and genetics have to be considered to decide on personalized APT. Ongoing studies have yet to reveal the optimal personalized APT strategy for cardiologists to prevent their patients from atherothrombotic and bleeding events.

Abstract 12886: Ten-year Trends in Patient Characteristics, Treatments, and Outcomes in St Elevation Mi Patients in the Us - A Report From NCDR CP-MI Registry

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sanjay Gandhi ◽  
Kirk N Garratt ◽  
Tracy Y Wang ◽  
Shuang Li ◽  
Deepak L Bhatt ◽  
...  
Keyword(s):  
Risk Model ◽  
Patient Characteristics ◽  
Stemi Patient ◽  
Primary Pci ◽  
P2y12 Inhibitors ◽  
Data Registry ◽  
The Us ◽  
Significant Change ◽  
Door To Balloon ◽  
Over Time

Introduction: The National Cardiovascular Data Registry affords a 10-year perspective of the landscape of STEMI patient characteristics, management, and clinical outcomes. Methods: Annual trends in patient characteristics and in-hospital treatments of 604,936 STEMI patients treated at 1226 US hospitals between 2009 and 2018 were analyzed. Using the ACTION mortality risk model incorporating cardiac arrest, the trend in in-hospitals risk adjusted mortality rates (RAMR) between 2011-2018 was tested. Results: While patient age (median 61 years) and sex (70.7% male) remained stable over time, the prevalence of diabetes (22.8% in 2009 to 28.3% in 2018) and atrial fibrillation (4.1% to 6.1%) increased, while smoking decreased (43.5% to 37.9%) . Among eligible patients, primary PCI use increased (82.3% to 96.0%) with more rapid door to balloon times for both direct arrival (median 62 min vs 56 min) and transferred-in pts (median 113 min vs 103 min, p for trend <0.001 for all). Thrombolytic use declined (10.1% to 5.0%) with no significant change in door to needle time (median 27 minutes). There was no significant change in RAMR (2.83% to 2.69%, p=0.46) from 2011-2018. (Figure 1). Discharge use of P2Y12 inhibitors (91.5% to 95.6%) and statins (94.9% to 98.5%) increased. Conclusions: Characteristics of patients presenting with STEMI changed over time with improvements in primary PCI use and timeliness. However, there was no significant reduction in risk-adjusted mortality over the past decade.

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