scholarly journals Ticagrelor in Acute Coronary Syndromes

2021 ◽  
Author(s):  
◽  
Charlotte Howard
Keyword(s):  
Myocardial Infarction ◽  
Real World ◽  
Platelet Reactivity ◽  
Controlled Trial ◽  
Platelet Inhibition ◽  
Adverse Outcomes ◽  
Risk Scores ◽  
Coronary Syndrome ◽  
Clinical Risk ◽  
P2y12 Receptor Antagonist

<p>The PLATO trial demonstrated significantly lower mortality and myocardial infarction in acute coronary syndrome (ACS) patients treated with ticagrelor and aspirin compared to clopidogrel and aspirin. Ticagrelor is a direct acting P2Y12 receptor antagonist, and is a more potent inhibitor of platelet reactivity than clopidogrel, and this is believed to be the main cause of its superior efficacy in the PLATO trial. A range of factors have been associated with high on-treatment platelet reactivity (HOTPR) on clopidogrel, including genetic factors, drug interactions and clinical risk factors. HOTPR on clopidogrel has been associated with a higher risk of adverse outcomes following ACS. On the basis of the PLATO trial results, and the theoretical limitations associated with clopidogrel, ticagrelor was funded by PHARMAC in July 2013, and has been recommended for use in patients with ACS in New Zealand.    This thesis examined the use of ticagrelor in a real world ACS population being managed through Wellington Hospital cardiology department. We examined platelet reactivity in patients treated with ticagrelor compared to clopidogrel, factors associated with clinician choice to use ticagrelor versus clopidogrel and the incidence of side effects of ticagrelor that may have implications for compliance with the drug outside the setting of a randomized controlled trial.   We found that ticagrelor significantly reduced both platelet reactivity (30.3 AU ± 17.5 versus 43.7 AU ± 24.8, p= 0.0001) and the proportion of patients classified as having HOTPR (15.9% versus 37.7%, p= 0.0001), in comparison to clopidogrel. The clinical variables associated with HOTPR differ between clopidogrel and ticagrelor, suggesting that different factors were driving residual platelet reactivity on the two agents.   Over a 2 year period, clopidogrel (68%) was used more commonly than ticagrelor (42%), and in a different cohort of patients. Patients treated with ticagrelor were younger (61 years ± 10 versus 65 years ± 12, p=0.0001), less likely to present with STEMI (12% versus 31%, p=0.0001), less likely to have a history of prior myocardial infarction (15.8% versus 22.7%, p=0.05), and had lower GRACE (98 ± 24 versus 108 ± 28, p=0.0001) and CRUSADE (25 ± 9 versus 28 ± 12, p=0.001) risk scores compared to those treated with clopidogrel. Prescription of ticagrelor was therefore not driven by clinical risk. Antiplatelet prescription varied significantly according to the patients’ admitting hospital.   Bleeding rates on ticagrelor and clopidogrel within 30 days of study enrolment were low and were not significantly different. There was 1 patient on clopidogrel who had the drug discontinued due to bleeding. At 30 day follow up, significantly more patients treated with ticagrelor reported dyspnoea (43.3% versus 27.1%, p=0.001), however discontinuation of the drug due to dyspnoea on ticagrelor was infrequent (1.7%).   In this real world cohort of ACS patients, we observed that ticagrelor was associated with more potent platelet inhibition than clopidogrel, but was not associated with factors leading to increased discontinuation at 30 days. Despite the proven benefits of ticagrelor compared to clopidogrel, the majority of patients, including the highest risk patients appear to be preferentially treated with clopidogrel. The causes contributing to underuse of ticagrelor need to be examined and addressed.</p>

scholarly journals Ticagrelor in Acute Coronary Syndromes

2021 ◽  
Author(s):  
◽  
Charlotte Howard
Keyword(s):  
Myocardial Infarction ◽  
Real World ◽  
Platelet Reactivity ◽  
Controlled Trial ◽  
Platelet Inhibition ◽  
Adverse Outcomes ◽  
Risk Scores ◽  
Coronary Syndrome ◽  
Clinical Risk ◽  
P2y12 Receptor Antagonist

<p>The PLATO trial demonstrated significantly lower mortality and myocardial infarction in acute coronary syndrome (ACS) patients treated with ticagrelor and aspirin compared to clopidogrel and aspirin. Ticagrelor is a direct acting P2Y12 receptor antagonist, and is a more potent inhibitor of platelet reactivity than clopidogrel, and this is believed to be the main cause of its superior efficacy in the PLATO trial. A range of factors have been associated with high on-treatment platelet reactivity (HOTPR) on clopidogrel, including genetic factors, drug interactions and clinical risk factors. HOTPR on clopidogrel has been associated with a higher risk of adverse outcomes following ACS. On the basis of the PLATO trial results, and the theoretical limitations associated with clopidogrel, ticagrelor was funded by PHARMAC in July 2013, and has been recommended for use in patients with ACS in New Zealand.    This thesis examined the use of ticagrelor in a real world ACS population being managed through Wellington Hospital cardiology department. We examined platelet reactivity in patients treated with ticagrelor compared to clopidogrel, factors associated with clinician choice to use ticagrelor versus clopidogrel and the incidence of side effects of ticagrelor that may have implications for compliance with the drug outside the setting of a randomized controlled trial.   We found that ticagrelor significantly reduced both platelet reactivity (30.3 AU ± 17.5 versus 43.7 AU ± 24.8, p= 0.0001) and the proportion of patients classified as having HOTPR (15.9% versus 37.7%, p= 0.0001), in comparison to clopidogrel. The clinical variables associated with HOTPR differ between clopidogrel and ticagrelor, suggesting that different factors were driving residual platelet reactivity on the two agents.   Over a 2 year period, clopidogrel (68%) was used more commonly than ticagrelor (42%), and in a different cohort of patients. Patients treated with ticagrelor were younger (61 years ± 10 versus 65 years ± 12, p=0.0001), less likely to present with STEMI (12% versus 31%, p=0.0001), less likely to have a history of prior myocardial infarction (15.8% versus 22.7%, p=0.05), and had lower GRACE (98 ± 24 versus 108 ± 28, p=0.0001) and CRUSADE (25 ± 9 versus 28 ± 12, p=0.001) risk scores compared to those treated with clopidogrel. Prescription of ticagrelor was therefore not driven by clinical risk. Antiplatelet prescription varied significantly according to the patients’ admitting hospital.   Bleeding rates on ticagrelor and clopidogrel within 30 days of study enrolment were low and were not significantly different. There was 1 patient on clopidogrel who had the drug discontinued due to bleeding. At 30 day follow up, significantly more patients treated with ticagrelor reported dyspnoea (43.3% versus 27.1%, p=0.001), however discontinuation of the drug due to dyspnoea on ticagrelor was infrequent (1.7%).   In this real world cohort of ACS patients, we observed that ticagrelor was associated with more potent platelet inhibition than clopidogrel, but was not associated with factors leading to increased discontinuation at 30 days. Despite the proven benefits of ticagrelor compared to clopidogrel, the majority of patients, including the highest risk patients appear to be preferentially treated with clopidogrel. The causes contributing to underuse of ticagrelor need to be examined and addressed.</p>

A real world analysis of NSTE-ACS in more than 4000 patients: accuracy of GRACE and TIMI scores in mortality prediction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J Borges-Rosa ◽  
J Ferreira ◽  
M Oliveira-Santos ◽  
S Monteiro ◽  
F Goncalves ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Risk Score ◽  
Real World ◽  
Predictive Accuracy ◽  
Characteristic Curve ◽  
Risk Scores ◽  
Coronary Syndrome ◽  
Timi Score ◽  
One Year ◽  
Grace Score

Abstract Introduction The TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) risk scores identify high-risk patients with Non-ST elevation acute coronary syndrome (NSTE-ACS) who can benefit from an early invasive strategy. Purpose We aimed to compare both scores predictive accuracy for mortality in a real-world cohort of patients presenting with NSTE-ACS. Methods We retrospectively evaluated 4264 patients admitted to our coronary intensive care unit between 2004 and 2017 with a diagnosis of NSTE-ACS. The TIMI and GRACE scores were calculated for each patient, and all-cause mortality was recorded during hospitalization, at one month and one year. To better characterize global troponin release, we defined Total Troponin (TT) as the sum of initial and discharge troponin. We used the area under the receiver operating characteristic curve (AUC) to compare the predictive value of both scores for mortality during hospitalization, at one month and one year. Results Mean patient age was 67.6±12.4 years and 66.4% were male (n=2833). Mean GRACE score was 124.6±35.8 and mean TIMI score was 2.7±1.6. There was a weak correlation between GRACE and TIMI score (r=0.3, p&lt;0.001). In-hospital mortality was 2.8%: the GRACE score showed higher AUC (0.845, 95% CI 0.805–0.804, p&lt;0.001) compared to TIMI (0.581, 95% CI 0.519–0.643, p=0.009) (Figure 1). Mortality at one month was 5.1%: the GRACE score showed higher AUC (0.842, 95% CI 0.814–0.869, p&lt;0.001) compared to TIMI (0.586, 95% CI 0.541–0.630, p&lt;0.001). Mortality at one year was 11.4%: the GRACE score showed higher AUC (0.811, 95% CI 0.789–0.822, p&lt;0.001) compared to TIMI (0.591, 95% CI 0.560–0.622, p&lt;0.001) (Fig. 1). Analyzing Unstable Angina and Non-ST segment elevation myocardial infarction separately, the GRACE score also showed higher AUC compared to TIMI. Exploratory analyses revealed a combined indicator (GRACE score + TT) which had higher AUC (0.876, 95% CI 0.844–0.907, p&lt;0.001) compared to GRACE score (0.855, 95% CI 0.823–0.887, p&lt;0.001) for one month mortality and for one year mortality (0.818, 95% CI 0.792–0.844, p&lt;0.001 vs. 0.813, 95% CI 0.788–0.839, p&lt;0.001). Conclusion In patients with NSTE-ACS, GRACE risk score is a better predictor of in-hospital, one month and one-year mortality, compared to TIMI risk score. TT, as a measure of ischemia burden, might improve accuracy of GRACE score in predicting short and long-term mortality. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Association of Dephosphorylated-Uncarboxylated Matrix Gla Protein and Risk of Major Bleeding in Patients Presenting with Acute Myocardial Infarction

Life ◽  
2021 ◽  
Vol 11 (8) ◽  
pp. 733
Author(s):  
Admira Bilalic ◽  
Tina Ticinovic Kurir ◽  
Josip A. Borovac ◽  
Marko Kumric ◽  
Daniela Supe-Domic ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Major Bleeding ◽  
Plasma Levels ◽  
Adverse Outcomes ◽  
Matrix Gla Protein ◽  
Coagulation Cascade ◽  
Bleeding Tendency ◽  
Coronary Syndrome ◽  
Bleeding Score

The “Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines” (CRUSADE) score emerged as a predictor of major bleeding in patients presenting with the acute coronary syndrome. On the other hand, previous studies established the association of dephosphorylated-uncarboxylated Matrix Gla protein (dp-ucMGP) and vitamin K, as well as their subsequent impact on coagulation cascade and bleeding tendency. Therefore, in the present study, we explored if dp-ucMGP plasma levels were associated with CRUSADE bleeding score. In this cross-sectional study, physical examination and clinical data, including plasma dp-ucMGP levels, were obtained from 80 consecutive patients with acute myocardial infarction (AMI). A significant positive correlation was found between CRUSADE bleeding score and both dp-ucMGP plasma levels (r = 0.442, p < 0.001) and risk score of in-hospital mortality (r = 0.520, p < 0.001), respectively. In comparing the three risk groups of risk for in-hospital bleeding, the high/very high-risk group had significantly higher dp-ucMGP levels from both very low/low group (1277 vs. 794 pmol/L, p < 0.001) and the moderate group (1277 vs. 941 pmol/L, p = 0.047). Overall, since higher dp-ucMGP levels were associated with elevated CRUSADE score and prolonged hemostasis parameters, this may suggest that there is a biological link between dp-ucMGP plasma levels and the risk of bleeding in patients who present with AMI.

scholarly journals Risk stratification score for acute myocardial infarction and sudden cardiac death in type 2 diabetes mellitus

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
S Lee ◽  
J Zhou ◽  
CL Guo ◽  
WKK Wu ◽  
WT Wong ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Myocardial Infarction ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Cardiac Death ◽  
Adverse Outcomes ◽  
Risk Scores ◽  
Diabetic Patients ◽  
Type 2 Diabetic

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute myocardial infarction (AMI) and sudden cardiac death (SCD) are major cardiovascular adverse outcomes in patients with type 2 diabetic mellitus. Although there are many risk scores on composite outcomes of major cardiovascular adverse outcomes or cardiovascular mortality for diabetic patients, these existing scores did not account for the difference in pathogenesis and prognosis between acute coronary syndrome and lethal ventricular arrhythmias. Furthermore, recent studies reported that HbA1c and lipid levels, which were often accounted for in these risk scores, have J/U-shaped relationships with adverse outcomes. Purpose The present study aims to evaluate the application of incorporating non-linear J/U-shaped relationships between mean HbA1c and cholesterol levels into risk scores for predicting for AMI and non-AMI related SCD respectively, amongst type 2 diabetes mellitus patients. Methods This was a territory-wide cohort study of patients with type 2 diabetes mellitus above the age 40 and free from prior AMI and SCD, with or without prescriptions of anti-diabetic agents between January 1st, 2009 to December 31st, 2009 at government-funded hospitals and clinics in Hong Kong. Risk scores were developed for predicting incident AMI and non-AMI related SCD. The performance of conditional inference survival forest (CISF) model compared to that of random survival forests (RSF) model and multivariate Cox model. Results This study included 261308 patients (age = 66.0 ± 11.8 years old, male = 47.6%, follow-up duration = 3552 ± 1201 days, diabetes duration = 4.77 ± 2.29 years). Mean HbA1c and high-density lipoprotein-cholesterol (HDL-C) were significant predictors of AMI under multivariate Cox regression and were linearly associated with AMI. Mean HbA1c and total cholesterol were significant multivariate predictors with a J-shaped relationship with non-AMI related SCD. The AMI and SCD risk scores had an area-under-the-curve (AUC) of 0.666 (95% confidence interval (CI)= [0.662, 0.669]) and 0.677 (95% CI= [0.673, 0.682]), respectively. CISF significantly improves prediction performance of both outcomes compared to RSF and multivariate Cox models. Conclusions A holistic combination of demographic, clinical, and laboratory indices can be used for the risk stratification of type 2 diabetic patients against AMI and SCD.

Primary care physician services and the frequency of comorbidities in patients with acute myocardial infarction

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
R King ◽  
D Giedrimiene
Keyword(s):  
Myocardial Infarction ◽  
Primary Care ◽  
Acute Myocardial Infarction ◽  
Primary Care Physician ◽  
Care Physician ◽  
Adverse Outcomes ◽  
Coronary Syndrome ◽  
Number Of Patients ◽  
Significant Difference ◽  
The Impact

Abstract Funding Acknowledgements Type of funding sources: None. Background The management of patients with multiple comorbidities represents a significant burden on healthcare each year. Despite requiring regular medical care to treat chronic conditions, a large number of these patients may not receive proper care. Significant disparities have been identified in patients with multiple comorbidities and those who experience acute coronary syndrome or acute myocardial infarction (AMI). Only limited data exists to identify the impact of comorbidities and utilization of primary care physician (PCP) services on the development of adverse outcomes, such as AMI. Purpose The primary objective was to analyze how PCP services utilization can be associated with comorbidities in patients who experienced an AMI. Methods This study was based on retrospective data analysis which included 250 patients admitted to the Hartford Hospital Emergency Department (ED) for an AMI. Out of these, 27 patients were excluded due to missing documentation. Collected data included age, gender, medications and recorded comorbidities, such as hypertension, hyperlipidemia, diabetes mellitus (DM), chronic kidney disease (CKD) and previous arrhythmia. Each patient was assessed regarding utilization of PCP services. Statistical analysis was performed in order to identify differences between patients with documented PCP services and those without by using the Chi-square test. Results The records allowed for identification of documented PCP services for 172 out of 223 (77.1%) patients. The most common comorbidities were hypertension and hyperlipidemia: in 165 (74.0%) and 157 (70.4%) cases respectively. The most frequent comorbidity was hypertension: 137 out of 172 (79.7%) in pts with PCP vs 28 out of 51 (54.9%) without PCP, and significantly more often in patients with PCP, p&lt; 0.001. Hyperlipidemia was the second most frequent comorbidity: in 130 out of 172 (75.6%) vs 27 out of 51 (52.9%) accordingly, and also significantly more often (p&lt; 0.002) in patients with PCP services. The number of comorbidities ranged from 0-5, including 32 (14.3%) patients without comorbidities: 16 (9.3%) with a PCP and 16 (31.4%) without PCP services. The majority of patients - 108 (48.5% of 223), had 2-3 documented comorbidities: 89 (51.8%) had two and 19 (34.6%) had three. The remaining 40 (17.9%) patients had 4-5 comorbidities: 37 (21.5%) of them with a PCP and 3 (10.3%) without, with a significant difference (p &lt; 0.001) found for patients with a higher number of comorbidities who utilized PCP services. Conclusions Our study shows that the majority of patients who presented with an AMI had one or more comorbidities. Furthermore, patients who did not utilize PCP services had fewer identified comorbidities. This suggests that there may be a significant number of patients who experienced AMI with undiagnosed comorbidities due to not having access to PCP services.

scholarly journals Does Baseline On-treatment Platelet Reactivity Impact Long-term Prognosis in Patients with Acute Coronary Syndrome and Thrombocytopenia Who Underwent Percutaneous Coronary Intervention?

2021 ◽  
Author(s):  
Ru Liu ◽  
Tianyu Li ◽  
Deshan Yuan ◽  
Yan Chen ◽  
Xiaofang Tang ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Acute Coronary Syndrome ◽  
Real World ◽  
Cox Regression ◽  
Platelet Reactivity ◽  
Coronary Intervention ◽  
The Real ◽  
Coronary Syndrome ◽  
Percutaneous Coronary

Abstract Objectives: This study analyzed the association between on-treatment platelet reactivity and long-term outcomes of patients with acute coronary syndrome (ACS) and thrombocytopenia (TP) in the real world. Methods: A total of 10724 consecutive cases with coronary artery disease who underwent percutaneous coronary intervention (PCI) were collected from January to December 2013. Cases with ACS and TP under dual anti-platelet therapy were enrolled from the total cohort. 5-year clinical outcomes were evaluated among cases with high on-treatment platelet reactivity (HTPR), low on-treatment platelet reactivity (LTPR) and normal on-treatment platelet reactivity (NTPR), tested by thromboelastogram (TEG) at baseline. Results: Cases with HTPR, LTPR and NTPR accounted for 26.2%, 34.4% and 39.5%, respectively. Cases with HTPR were presented with the most male sex, lowest hemoglobin level, highest erythrocyte sedimentation rate and most LM or three-vessel disease, compared with the other two groups. The rates of 5-year all-cause death, major adverse cardiovascular and cerebrovascular events (MACCE), cardiac death, myocardial infarction (MI), revascularization, stroke and bleeding were all not significantly different among three groups. Multivariable Cox regression indicated that, compared with cases with NTPR, cases with HTPR were not independently associated with all endpoints, as well as cases with LTPR (all P>0.05). Conclusions: In patients with ACS and TP undergoing PCI, 5-year all-cause death, MACCE, MI, revascularization, stroke and bleeding risk were all similar between cases with HTPR and cases with NTPR, tested by TEG at baseline, in the real world. The comparison result was the same between cases with LTPR and NTPR.

On-ticagrelor platelet reactivity and clinical outcome in patients undergoing percutaneous coronary intervention for acute coronary syndrome

2020 ◽  
Author(s):  
marc laine ◽  
Vassili PANAGIDES ◽  
Corinne Frère ◽  
thomas cuisset ◽  
Caroline Gouarne ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Percutaneous Coronary Intervention ◽  
Acute Coronary Syndrome ◽  
Clinical Outcome ◽  
Platelet Reactivity ◽  
Coronary Intervention ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
The Relationship

Background: A strong association between on-thienopyridines platelet reactivity (PR) and the risk of both thrombotic and bleeding events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) has been demonstrated. However, no study has analyzed the relationship between on-ticagrelor PR and clinical outcome in this clinical setting. Objectives: We aimed to investigate the relationship between on-ticagrelor PR, assessed by the vasodilator-stimulated phosphoprotein (VASP) index, and clinical outcome in patients with ACS undergoing PCI. Methods: We performed a prospective, multicenter, observational study of patients undergoing PCI for ACS. PR was measured using the VASP index following ticagrelor loading dose. The primary study endpoint was the rate of Bleeding Academic Research Consortium (BARC) type ≥2 at 1 year. The key secondary endpoint was the rate of major cardiovascular events (MACE) defined as the composite of cardiovascular death, myocardial infarction and urgent revascularization. Results: We included 570 ACS patients, among whom 33.9% had ST-elevation myocardial infarction. BARC type ≥ 2 bleeding occurred in 10.9% and MACE in 13.8%. PR was not associated with BARC ≥ 2 or with MACE (p=0.12 and p=0.56, respectively). No relationship between PR and outcomes was observed, neither when PR was analyzed quantitatively nor qualitatively (low on-treatment PR (LTPR) vs no LTPR). Conclusion: On-ticagrelor PR measured by the VASP was not associated with bleeding or thrombotic events in ACS patients undergoing PCI. PR measured by the VASP should not be used as a surrogate endpoint in studies on ticagrelor.

Comparison of methods to evaluate clopidogrel-mediated platelet inhibition after percutaneous intervention with stent implantation

2009 ◽  
Vol 101 (02) ◽  
pp. 333-339 ◽  
Author(s):  
Sabine Steiner ◽  
Daniela Seidinger ◽  
Renate Koppensteiner ◽  
Thomas Gremmel ◽  
Simon Panzer ◽  
...  
Keyword(s):  
Stent Implantation ◽  
Light Transmission ◽  
Platelet Reactivity ◽  
Platelet Inhibition ◽  
Percutaneous Intervention ◽  
Adverse Outcomes ◽  
Gold Standard Method ◽  
Platelet Aggregometry ◽  
Increased Risk ◽  
The Impact

SummaryA high on-treatment residual ADP-inducible platelet reactivity in light transmission aggregometry (LTA) has been associated with an increased risk of adverse outcomes after percutaneous coronary intervention (PCI). However, LTA is weakly standardized, and results obtained in one laboratory may not be comparable to those obtained in another one. We therefore sought to determine the test correlating best with LTA to estimate clopidogrel-mediated platelet inhibition in 80 patients on dual antiplatelet therapy after elective percutaneous intervention with stent implantation. We selected the VerifyNow P2Y12 assay, the vasodilator-stimulated phosphoprotein phosphorylation assay, multiple electrode platelet aggregometry and the Impact-R for comparisons with LTA. Cut-off values for residual ADP-inducible platelet reactivity were defined according to quartiles of each assay. Sensitivities and specificities of the different platelet function tests were based on the results from LTA. The results from all four assays correlated significantly with those from LTA. The VerifyNow P2Y12 assay revealed the strongest correlation (r = 0.61, p < 0.001). Sensitivities and specificities ranged from 35% to 55%, and from 78.3% to 85%, respectively. In conclusion, although all assays correlated significantly with LTA, they need to be improved to become clinically used diagnostic tests. Further, it may be too early to define the gold standard method for assessing residual ADP-inducible platelet reactivity and generally acceptable cut-off values.

Sign in / Sign up

Export Citation Format

Share Document