Impact of shifting from routine use of ticagrelor to prasugrel in myocardial infarction patients after PCI: a nationwide cohort study

Background: The PEGASUS trial demonstrated a reduction in ischemic events following P2Y 12 inhibition with ticagrelor among patients with a prior MI. The implications of these findings for clinical practice are unknown. Methods: We sought to determine the proportion of real-world myocardial infarction (MI) patients who would have been eligible for the PEGASUS-TIMI 54 trial, to characterize their current use of P2Y12 inhibitors, and to explore the estimated costs and ischemic event consequences of increasing P2Y12 inhibitor use among these patients. In the U.S. national ACTION Registry-GWTG, We identified 273,328 MI patients and determined the proportion that would have met the eligibility criteria for the PEGASUS trial. We described longitudinal P2Y 12 inhibitor use among PEGASUS eligible patients and estimated the cost and ischemic consequences of increasing P2Y 12 use among eligible patients. Results: A total of 112,222 (41.1%) MI patients in ACTION Registry-GWTG met eligibility for the PEGASUS trial. Among 83,871 eligible patients with pharmacy claims data, 23,042 (27.5%) were on a P2Y 12 inhibitor at 1 year, 9,661 (11.5%) at 2 years, and 5,246 (6.3%) at 3 years (see Figure), with the majority (79.2%) of these patients on clopidogrel. Use of ticagrelor in eligible patients not already on a P2Y 12 inhibitor at 1-year post MI would cost an estimated $885,000 per myocardial infarction, stroke, or cardiovascular death averted over a 3-year time horizon, while use of clopidogrel would cost an estimated $19,800 per ischemic event averted. Conclusions: In contemporary clinical practice, a minority of patients are on a P2Y 12 inhibitor beyond 1-year post-MI. Applying PEGASUS trial findings to clinical practice would result in a large increase in P2Y 12 inhibitor use with a cost per ischemic event averted that is strongly influenced by the choice of therapy.

We aimed to investigate the long-term cardio-protective effect associated with beta-blocker (BB) treatment in stable, optimally treated myocardial infarction (MI) patients without heart failure (HF). Using nationwide registries, we included patients with first-time MI undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) during admission and treated with both acetyl-salicylic acid and statins post-discharge between 2003 and 2018. Patients with prior history of MI, prior BB use, or any alternative indication or contraindication for BB treatment were excluded. Follow-up began 3 months following discharge in patients alive, free of cardiovascular (CV) events or procedures. Primary outcomes were CV death, recurrent MI, and a composite outcome of CV events. We used adjusted logistic regression and reported standardized absolute risks and differences (ARD) 3 years after MI. Overall, 30177 stable, optimally treated MI patients were included (58% acute PCI, 26% sub-acute PCI, 16% CAG without intervention). At baseline, 82% of patients were on BB treatment (median age 61 years, 75% male) and 18% were not (median age 62 years, 68% male). BB treatment was associated with a similar risk of CV death, recurrent MI, and the composite outcome of CV events compared with no BB treatment [ARD (95% confidence intervals)] correspondingly; 0.1% (-0.3% to 0.5%), 0.2% (-0.7% to 1.2%), and 1.2% (-0.2% to 2.7%). In this nationwide cohort study of stable, optimally treated MI patients without HF, we found no long-term effect of BB treatment on CV prognosis following the patients from 3 months to 3 years after MI admission.

Acute myocardial infarction in patients with atrial fibrillation with a CHA2DS2-VASc score of 0 or 1: a nationwide cohort study.

Use of calcium channel blockers and myocardial infarction in hypertensive patients with rheumatoid arthritis – A nationwide cohort study

Sparse information regarding the long-term risk of acute myocardial infarction (MI) following a transient ischemic attack (TIA) emphasizes further research to guide preventive strategies and risk stratification in patients with a TIA. We conducted a nationwide cohort study to investigate the 5-year risk of MI and all-cause mortality in patients with a first-time TIA. Patients with a first-time TIA were identified in the Danish Stroke Registry (2013-2020), matched on age, sex, and calendar year (1:4) with the general population and (1:1) with patients with first-time ischemic stroke. The 5-year risks of MI and all-cause mortality were estimated by the Aalen-Johansen and Kaplan-Meier estimators. The groups were compared using Cox regression, while adjusting for cardiovascular comorbidities. We identified 21 743 patients with TIA, 86 972 matched individuals from the general population, and 21 743 matched control patients with ischemic stroke. Median age was 70 (25th to 75th percentile, 60-78) years; 52% were male. Comorbidity burden was the lowest in general population controls, intermediate in patients with TIA, and the highest in patients with ischemic stroke. The 5-year risk of MI was 2.0% in patients with TIA, 1.5% in the general population (P<0.001), and 2.2% in the ischemic stroke population (P<0.001). After adjustment, these differences in MI rate were similar (TIA versus general population; hazard ratio, 0.99 [95% CI, 0.98-1.02] and TIA versus ischemic stroke; hazard ratio, 0.99 [95% CI, 0.96-1.01]). The 5-year risk of mortality was 17.0% in patients with TIA compared with 14.0% in the general population (P<0.001) and 27.0% in ischemic stroke population (P<0.001). The differences in mortality persisted following adjustments for patients with TIA versus general population (hazard ratio, 1.25 [95% CI, 1.19-1.31]) and for patients with TIA versus ischemic stroke (hazard ratio, 0.43 [95% CI, 0.41-0.46]). Patients with first-time TIA had a low 5-year incidence of MI, which was not significantly different from that of the general population and patients with first-time ischemic stroke after adjustments for comorbidities. However, patients with TIA had a 25% higher all-cause mortality rate than the general population, which was not readily explained by MI risk. Hence, the findings do not endorse the need to raise further awareness regarding MI in patients with TIA.

Objective To evaluate the efficacy and safety of combined use of ticagrelor and cilostazol for patients with acute coronary syndrome (ACS) complicated with upper digestive tract diseases following percutaneous coronary intervention (PCI). Methods A total of 262 consecutive ACS patients complicated with upper digestive tract diseases followed-up for one-year after PCI were included in this study. The patients were allocated into control group (combined use of ticagrelor and aspirin, n=184) and cilostazol group (combined use of ticagrelor and cilostazol, n=78) for antiplatelet treatment. The basic characteristics of the patients, change of the treatment regimens, cardiovascular events and hemorrhagic events were compared between two groups. Results After one year of follow-up, 16.8%(31/184)patients in control group and 3.8%(3/78)in cilostazol group changed antiplatelet regimens(χ2=8.200, P=0.004). There was no statistical difference in use of statins and ACEI/ARB between two groups(P>0.05). The rate of proton pump inhibitor use in control group was significantly higher than that in cilostazol group [82.1% (151/184) vs. 52.6%(41/78), χ2=24.35, P=0.000]. However, the dosage of β-blockers in cilostazol group was significantly higher than that in control group [(39.1±12.4)mg vs. (28.6±10.1)mg, t=7.174, P=0.000]. No statistical difference was found in total cardiovascular events between two groups [21.7% (40/184) vs.12.8%(10/78), χ2=2.822, P=0.121]. The incidence of gastrointestinal hemorrhage in control group was significantly increased compared with cilostazol group [12.0%(22/184) vs. 2.6%(2/78), χ2=5.807, P=0.018], however, there was no significant difference in hemorrhagic events concerning the thrombolysis for myocardial infarction between two groups [17.4%(32/184) vs. 9.0%(7/78), χ2=3.063, P=0.089]. Conclusion Combined use of cilostazol and ticagrelor is effective and safe for ACS patients with gastrointestinal hemorrhage or a higher risk of hemorrhage. Key words: Acute coronary syndrome; Platelet aggregation inhibitors; Aspirin; Hemorrhage

Background In clinical trials, patients with myocardial infarction (MI) and elevated LDL-cholesterol (LDL-C) benefit the most from lipid lowering therapy, and more intensive LDL-C lowering therapy is associated with better prognosis. Purpose To investigate the association between degree of LDL-C lowering and prognosis in MI patients from a large real-world setting. Methods Patients admitted with an MI between 2006 and 2016 and registered in the Swedish MI-registry (SWEDEHEART) were followed until 2018. The difference in LDL-C between the MI hospitalization and a 6–10 week follow-up was measured. In multivariable Cox regression analysis adjusting for clinical risk factors (eg. age, diabetes, prior cardiovascular disease), the association between LDL-C change, mortality and recurrent MI was assessed using restricted cubic splines. Further, the patients were stratified according to quartile decrease in LDL-C from MI hospitalization to the follow-up. Results A total of 44,148 patients (median age: 64) had an LDL-C measured during the MI hospitalization and at follow-up. Of these, 9,905 (22.4%) had ongoing statin treatment prior to admission. The median LDL-C at the MI hospitalization was 2.96 (interquartile range 2.23, 3.74) mmol/L and the median decrease in LDL-C was 1.17 (0.37, 1.86) mmol/L. During a median follow-up of 3.9 years, 3,342 patients died and 3,210 had an MI. Patients with the highest quartile of LDL-C decrease (1.86 mmol/L) from index event to follow-up, had a lower risk of mortality, hazard ratio (HR) 0.59 (95% confidence interval [CI] 0.44–0.80) compared to those with the lowest quartile of LDL-C decrease (0.37 mmol/L) (figure). For MI, the corresponding HR was 0.83 (95% CI 0.68–1.02). Ongoing statin-use prior to admission did not alter the effect of LDL-C decrease and outcome in the analysis. Conclusions In this large nationwide cohort of MI patients, a gradually lower risk of death was observed in patients with larger decrease in LDL-C from index event to follow-up, regardless of statin use prior to admission. The same trend was observed for recurrent MI, although not reaching statistical significance. This confirms previous findings that efforts should be made to lower LDL-C after MI.

REAL-WORLD EFFICACY AND SAFETY OF DUAL ANTIPLATELET THERAPY WITH TICAGRELOR AS COMPARED TO CLOPIDOGREL

Acute Myocardial Infarction While Using the Nicotine Patch

BackgroundDiabetes mellitus (DM) is considered a major risk factor for myocardial infarction (MI), and MI patients with DM have a poor prognosis. Accordingly, we aimed to investigate the additive effects of DM on LV deformation in patients after acute MI.Materials and methodsOne hundred thirteen MI patients without DM [MI (DM−)], 95 with DM [MI (DM+)] and 71 control subjects who underwent CMRscanning were included. LV function, infarct size and LV global peak strains in the radial, circumferential and longitudinal directions were measured. MI (DM+) patients were divided into two subgroups based on the HbA1c level (< 7.0% and ≥ 7.0%). The determinants of reduced LV global myocardial strain for all MI patients and MI (DM+) patients were assessed using multivariable linear regression analyses.ResultsCompared with control subjects, both MI (DM−) and MI (DM+) patients presented higher LV end-diastolic and end-systolic volume index and lower LV ejection fraction. LV global peak strains progressively declined from the control group to the MI(DM−) group to the MI(DM+) group (all p < 0.05). Subgroup analysis showed that LV global radial PS and longitudinal PS were worse in MI(MD+) patients with poor glycemic control than in those with good glycemic control (all p < 0.05). DM was an independent determinant of impaired LV global peak strain in radial, circumferential and longitudinal directions in patients after acute MI (β = − 0.166, 0.164 and 0.262, both p < 0.05). The HbA1c level was independently associated with a decreased LV global radial PS (β = − 0.209, p = 0.025) and longitudinal PS (β = 0.221, p = 0.010) in MI (DM+) patients.ConclusionsDM has an additive deleterious effect on LV function and deformation in patients after acute MI, and HbA1c was independently associated with impaired LV myocardial strain.

To examine the effect of de-escalation of P2Y12 inhibitor in dual antiplatelet therapy (DAPT) on major adverse cardiovascular events (MACE) and bleeding complications after acute myocardial infarction (AMI) in Taiwanese patients undergoing percutaneous coronary intervention (PCI). Patients who had received PCI during hospitalization for AMI (between 2013 and 2016) and were initially treated with aspirin and ticagrelor and without adverse events after 3 months of treatment were retrospectively evaluated. In total, 1,901 and 8,199 patients were identified as “de-escalated DAPT” (switched to aspirin and clopidogrel) and “unchanged DAPT” (continued on aspirin and ticagrelor) cohorts, respectively. With a mean follow-up of 8 months, the incidence rates (per 100 person-year) of death, AMI readmission and MACE were 2.89, 3.68, and 4.91 in the de-escalated cohort and 2.42, 3.28, and 4.72 in the unchanged cohort, respectively, based on an inverse probability of treatment weighted approach that adjusting for baseline characteristics of the patients. Multivariate Cox regression analyses showed the two groups had no significant differences in the hazard risk of death, AMI admission, and MACE. Additionally, there was no observed difference in the risk of bleeding, including major or clinically relevant non-major bleeding. The real-world data revealed that de-escalation of P2Y12 inhibitor in DAPT was not associated with a higher risk of death or AMI readmission in Taiwanese patients with AMI undergoing successful PCI.

Background Recently, both unguided (platelet function testing independent) and guided (platelet function testing dependent) DAPT de-escalation strategies have been investigated in different clinical studies but the data is still limited and conflicting. The aim of this study was to examine the effect of switching dual antiplatelet therapy (DAPT) on the major vascular risk after acute myocardial infarction (AMI) in patients undergoing percutaneous coronary intervention (PCI) by using Taiwan National Health Insurance Research Database. Methods In total, 1,903 and 4,059 patients defined as switched to aspirin and clopidogrel (switched DAPT) and continuation of aspirin and ticagrelor (unswitched DAPT) cohort, respectively who had received PCI during AMI hospitalization, on aspirin and ticagrelor initially and without occurring adverse events at 3 months were evaluated between 2013 and 2015. An inverse probability treatment of weighted approach was adopted to balance the baseline differences between two groups and Cox proportional hazard regression and competing risk regression were used to evaluated the effect of switching DAPT on death, AMI readmission, major bleeding and non-major clinically relevant bleeding. Results The incidence rates (per 100 person-year) of death and AMI readmission were 3.97 (95% confidence interval [CI] = 3.19–4.84) and 3.84 (95% CI = 3.09–4.73) in switched cohort and 1.83 (95% CI = 1.47–2.24) and 2.23 (95% CI = 1.82–2.68) in unswitched cohort, respectively. After adjustment for patients' clinical variables, switched cohort had higher risk of death (adjusted hazard ratio = 2.18, 95% CI = 1.62–2.93, P&lt;0.001), and AMI readmission (adjusted sub-distribution ratio = 1.72, 95% CI = 1.27–2.34, P&lt;0.001) compared to these in unswitched cohort; however, there was no difference in the risk of bleeding. Subgroup analysis showed a similar findings in many specific groups, except the patients who were younger age and had lower comorbidity score. Conclusion Switching DAPT might increase the risk of death and AMI readmission among patients with AMI undergoing PCI.

Aims To examine the effect of de-escalation of P2Y12 inhibitor in dual antiplatelet therapy (DAPT) on major adverse cardiovascular events (MACE) and bleeding complications after acute myocardial infarction (AMI) in Taiwanese patients undergoing percutaneous coronary intervention (PCI). Methods and results We retrospectively evaluated patients who had received PCI during AMI hospitalisation and were initially on aspirin and ticagrelor and without adverse events at 3 months between 2013 and 2016. In total, 1,901 and 8,199 patients were identified as switched DAPT (switched to aspirin and clopidogrel) and unswitched DAPT (continued on aspirin and ticagrelor) cohorts, respectively. With a mean follow-up of 8 months, the incidence rates (per 100 person-year) of death, AMI readmission and MACE were 2.89, 3.68 and 4.91 in the switched cohort and 2.42, 3.28 and 4.72 in the unswitched cohort, respectively based on an inverse probability of treatment weighted method. (Table) After adjustment for patients' clinical variables, two groups were no significant difference in death (A), AMI admission (B) and MACE (C). Additionally, there was no difference in the risk of major (D) or non-major clinically relevant bleeding (E) (Figure 1). Conclusions Unguided de-escalation of P2Y12 inhibitor in DAPT was not associated with higher risk of death, MACE, AMI readmission in Taiwanese patients with AMI undergoing PCI. Figure 1 Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Taipei Medical University

To examine the effect of de-escalation of P2Y12 inhibitor in dual antiplatelet therapy (DAPT) on major adverse cardiovascular events (MACE) and bleeding complications after acute myocardial infarction (AMI) in Taiwanese patients undergoing percutaneous coronary intervention (PCI). Patients who had received PCI during hospitalization for AMI (between 2013 and 2016) and were initially treated with aspirin and ticagrelor and without adverse events after 3 months of treatment were retrospectively evaluated. In total, 1,901 and 8,199 patients were identified as "de-escalated DAPT" (switched to aspirin and clopidogrel) and "unchanged DAPT" (continued on aspirin and ticagrelor) cohorts, respectively. With a mean follow-up of 8 months, the incidence rates (per 100 person-year) of death, AMI readmission and MACE were 2.89, 3.68, and 4.91 in the de-escalated cohort and 2.42, 3.28, and 4.72 in the unchanged cohort, respectively, based on an inverse probability of treatment weighted approach that adjusting for baseline characteristics of the patients. Multivariate Cox regression analyses showed the two groups had no significant differences in the hazard risk of death, AMI admission, and MACE. Additionally, there was no observed difference in the risk of bleeding, including major or clinically relevant non-major bleeding. The real-world data revealed that de-escalation of P2Y12 inhibitor in DAPT was not associated with a higher risk of death or AMI readmission in Taiwanese patients with AMI undergoing successful PCI.

Resting gated pool ejection fraction: a poor predictor of perioperative myocardial infarction in patients undergoing vascular surgery for infrainguinal bypass grafting