GReek AntiPlatElet Registry Research Articles

Contemporary Antiplatelet Treatment in Acute Coronary Syndrome Patients with Impaired Renal Function Undergoing Percutaneous Coronary Intervention

Objectives: To assess the clinical impact of impaired renal function (IRF), in “real-world” acute coronary syndrome (ACS) patients, receiving clopidogrel, prasugrel, or ticagrelor. Methods: This was a prospective, observational, multicenter, cohort study of ACS patients undergoing percutaneous coronary interventions (PCI) with IRF (creatinine clearance <60 mL/min by Cockroft-Gault equation), who were recruited into the Greek Antiplatelet Registry (GRAPE). Patients were followed-up until 1 year for major adverse cardiovascular events (MACE; a composite of death, nonfatal myocardial infarction, urgent revascularization, and stroke) and BARC (Bleeding Academic Research Consortium) bleeding. Results: Out of 2,047 registered patients, there were 344 (16.8%) with IRF. At the 1-year follow-up, MACE occurred in 18.6 and 6.2% of those patients with and without IRF, respectively: adjusted hazard ratio (HR) = 2.13 (95% confidence interval, CI 1.16-3.91), p = 0.02. IRF patients were also at higher risk of death and BARC type ≥2 and ≥3 bleeding: adjusted HR = 3.55 (95% CI 1.73-7.27), p = 0.001; HR = 2.75 (95% CI 1.13-6.68), p = 0.03; and HR = 6.02 (95% CI 2.30-15.77), p < 0.001, respectively. Combined MACE and BARC type ≥2 bleeding occurred in 34.0 and 14.0% of those with and without IRF, respectively: adjusted HR = 2.65 (95% CI 1.36-5.16), p = 0.004. At discharge, clopidogrel was more frequently prescribed in IRF patients (61.0 vs. 33.1%, p < 0.001). Conclusions: Real-world ACS patients with IRF subjected to PCI demonstrate higher thrombotic and bleeding risks than patients with normal renal function.

Gender-related differences in antiplatelet treatment patterns and outcome: Insights from the GReekAntiPlatElet Registry.

Data on the clinical impact of gender in "real-life" patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), receiving clopidogrel, prasugrel, or ticagrelor are limited. We aimed to investigate sex-based differences in clinical outcome of those patients. In a prospective, observational, multicenter, cohort study, 2047 patients were recruited into the GReekAntiPlatElet (GRAPE) Registry and were followed up until 1year for major adverse cardiovascular events (MACE, composite of death, nonfatal myocardial infarction, urgent revascularization, and stroke) and bleeding events (Bleeding Academic Research Consortium [BARC] classification). Women (n=360, 17.6%) were more frequently administered clopidogrel (rather than novel P2Y12 receptor antagonists) at PCI hospital and at discharge. MACE occurred in 9.2% and 8.1% of women and men, respectively and did not differ significantly by gender. Rate of observed bleeding BARC any type was 57.2% and 44.4% in women and men, respectively. Following adjustment, only differences in BARC any type and BARC type 1 events remained significant, with higher rates observed between women: hazard ratio (95% confidence interval) 1.51 (1.23-1.85) and 1.58 (1.27-1.96), respectively, P<.001 for both. In a contemporary "real-life" cohort of patients with ACS treated with PCI and focusing on antiplatelet treatment 1-year ischemic outcome does not differ by gender, while women do present more frequently not actionable bleeding events.

Bivalirudin Use and One‐Month Outcome in the Context of Contemporary Antiplatelet Treatment: Insights from the Greek Antiplatelet Registry

Little is known about the use of bivalirudin in "real life". In the context of contemporary antiplatelet treatment, we aimed to assess bivalirudin treatment patterns and short-term (one-month) outcome. Greek Antiplatelet Registry (GRAPE) is a prospective, observational, multicenter cohort study of consecutive, moderate-to-high-risk acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI). We assessed bivalirudin treatment patterns and predictive factors for its use. Combined in-hospital and one-month major adverse cardiovascular events (MACE, including death, myocardial infarction, urgent revascularization, and stroke), and bleeding events according to Bleeding Academic Research Consortium (BARC) criteria were analyzed after propensity matching. Of 2047 registered patients, 480 (23.4%) were treated with bivalirudin. Multivariate analysis (C statistic 0.77, 0.75-0.80 95% CIs, P < 0.001) revealed as factors favoring bivalirudin use primary PCI, radial arterial access, presentation with positive biomarkers and use of novel P2Y12 inhibitor, whereas IIb/IIIa inhibitor administration did not. Regional trends also affected bivalirudin's choice. In 370 propensity-matched pairs of patients who received or not bivalirudin, MACE, BARC type 1, 2 and 3 did not differ between groups: 4.1%, 21.9%, 3.2%, 3.5% and 5.1%, 18.9%, 2.7%, 4.3%, respectively, P = nonsignificant for all. In a "real life", contemporary antiplatelet treatment registry, clinical, laboratory and logistic factors affect bivalirudin's choice, while there are no differences in one-month outcome between bivalirudin-treated and non-bivalirudin-treated patients.

In-hospital bleeding events in acute coronary syndrome patients undergoing percutaneous coronary intervention in the era of novel P2Y12 inhibitors: Insights from the GReek AntiPlatelet rEgistry–GRAPE

Ioanna Xanthopoulou , Spyridon Deftereos , George Sitafidis , Ioannis Kanakakis , Michalis Hamilos , George Karayannis , Christos Angelidis , Katerina Stavrou , Manolis Vavuranakis , John A. Goudevenos , Christodoulos Stefanadis , Dimitrios Alexopoulos a,⁎ a Patras University Hospital, Department of Cardiology, Patras, Greece b Athens General Hospital “G. Gennimatas”, Department of Cardiology, Athens, Greece c Larissa University Hospital, Department of Cardiology, Larissa, Greece d Alexandra General Hospital, Department of Cardiology, Athens, Greece e Iraklion University Hospital, Department of Cardiology, Iraklion, Greece f Ippokration General Hospital, 1st Department of Cardiology, Athens, Greece g Ioannina University Hospital, Department of Cardiology, Ioannina, Greece

Contraindications/Special Warnings and Precautions for Use of Contemporary Oral Antiplatelet Treatment in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

The prevalence of contraindications/special warnings and precautions (CON/SWP) for clopidogrel, prasugrel and ticagrelor use is not adequately studied and might affect P2Y12 inhibitor choice in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). In the context of the GReek AntiPlatelet rEgistry (GRAPE) a detailed recording of CON/SWP for use of clopidogrel, prasugrel and ticagrelor was done for 1,280 consecutive, moderate-high-risk ACS patients undergoing PCI. At least 1 CON for use of clopidogrel, prasugrel and ticagrelor was present in 5 (0.4%), 49 (3.8%) and 12 patients (0.9%), respectively. Prevalence of at least 1 CON/SWP to clopidogrel (45.8%) was less frequent compared to prasugrel (49.1%) or ticagrelor (49.1%; P=0.02 and P=0.04, respectively), while 34% of patients had at least 1 CON/SWP to all the 3 P2Y12 inhibitors. At discharge, 482 (38.6%), 301 (24.1%) and 464 patients (37.2%) received clopidogrel, prasugrel and ticagrelor, respectively. Age ≥75 years, co-medication related to increased bleeding risk, and history of asthma/chronic obstructive pulmonary disease favored clopidogrel vs. prasugrel or ticagrelor use as discharge medication, while geographic region also affected this choice (C-statistic, 0.81; 95% CI: 0.78-0.83). In patients with ACS undergoing PCI the prevalence of CON to antiplatelet agents is low, whereas that of SWP is high. Certain SWP, along with regional trends may affect the choice of newer P2Y12 inhibitors vs. clopidogrel.

In-hospital switching of oral P2Y12 inhibitor treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention: Prevalence, predictors and short-term outcome

P2Y12 inhibitor switching has appeared in clinical practice as a consequence of prasugrel and ticagrelor availability, apart from clopidogrel, for use in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). In the context of the GReek AntiPlatelet REgistry (GRAPE) we assessed the prevalence, predictive factors and short-term outcome of in-hospital P2Y12 inhibitor switching in 1794 ACS patients undergoing PCI. Switching occurred in 636 (35.5%) patients of which in the form of clopidogrel to a novel agent, novel agent to clopidogrel and between prasugrel and ticagrelor in 574 (90.4%), 34 (5.3%) and 27 (4.3%) patients, respectively. Presentation to non PCI-capable hospital, bivalirudin use, age ≥75 years (inverse predictor), and regional trends emerged as predictive factors of switching to a novel agent. At combined in-hospital and one-month follow-up, propensity matched pairs analysis showed no differences in major adverse cardiovascular (MACE) or bleeding events between switching from clopidogrel to a novel agent vs novel agent constant administration. More Bleeding Academic Research Consortium type 1, type 2 and any type events and fewer MACE were seen when switching from clopidogrel to a novel agent vs only clopidogrel administration (23.7%, 3.8%, 30.6%, 1.2% vs 8.9%, 1.2%, 12.0%, 3.8% with P < .001, P = .03, P < .001 and P = .03 respectively). In a real-life experience with contemporary antiplatelet treatment in ACS patients undergoing PCI, in-hospital switching represents common clinical practice. Clinical factors and regional practice differences seem to affect this strategy's choice, while switching to a novel agent may be associated with higher risk of bleeding.

Implementation of contemporary oral antiplatelet treatment guidelines in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A report from the GReek AntiPlatelet rEgistry (GRAPE)

BackgroundFew data exist about the implementation of contemporary oral antiplatelet treatment guidelines in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). MethodsGReek AntiPlatelet rEgistry (GRAPE), initiated on January 2012, is a prospective, observational, multicenter cohort study focusing on contemporary use of P2Y12 inhibitors. In 1434 patients we evaluated appropriateness of P2Y12 selection initially and at discharge by applying an eligibility-assessing algorithm based on P2Y12 inhibitors' contraindications/specific warnings and precautions. ResultsAppropriate, less preferable and inappropriate P2Y12 inhibitor selections were made initially in 45.8%, 47.2% and 6.6% and at discharge in 64.1%, 29.2% and 6.6% of patients, respectively. The selection of clopidogrel was most commonly less preferable, both initially (69.7%) and at discharge (75.6%). Appropriate selection of newer agents was high initially (79.2%–82.8%), with further increase as selection at discharge (89.4%–89.8%). Inappropriate selection of the newer agents was 17.2%–20.8% initially, decreasing to 10.2%–10.6% at discharge. Conditions and co-medications related to increased bleeding risk, presentation with ST elevation myocardial infarction and the absence of reperfusion within the first 24h were the most powerful predictors of appropriate P2Y12 selection initially, whereas age ≥75years, conditions and co-medications related to increased bleeding risk and regional trends mostly affected appropriate P2Y12 selection at discharge. ConclusionsIn GRAPE, adherence with the recently released guidelines on oral antiplatelet therapy was satisfactory. Clopidogrel was most commonly used as a less preferable selection, while prasugrel or ticagrelor selection was mostly appropriate. Certain factors may predict initial and at discharge guideline implementation.Clinical Trial Registration-clinicaltrials.gov Identifier: NCT01774955http://clinicaltrials.gov/.

In-hospital bleeding in the era of newer P2Y12 inhibitors in real-life patients with acute coronary syndrome: results from the GReek AntiPlatElet (GRAPE) registry

Purpose: Data on in-hospital bleeding events with the concurrent use of clopidogrel, prasugrel and ticagrelor in real-life practice are lacking. Methods: In the context of GReek AntiPlatelet rEgistry (GRAPE), a prospective, observational, multicenter cohort study conducted in in 8 PCI-capable hospitals in Greece, we investigated in-hospital bleeding events (Bleeding Academic Research Consortium -BARC classification) in ACS patients undergoing percutaneous coronary intervention (PCI). Results: Between January and December 2012, 1280 patients were included in analysis (82.8% men, 22.7% diabetics, 53.5% admitted with ST elevation myocardial infarction (STEMI), with a mean age of 61.8±12.4 years). Overall, in-hospital bleeding BARC type 1, 2 3a and 3b occurred in 54 (4.2%), 31 (2.4%), 21 (1.6%) and 5 (0.4%) patients respectively. No fatal bleeding event occurred. In the subgroup of patients who were initially treated either with clopidogrel (N=478), prasugrel (N=92) or ticagrelor (N=228) without switching thereafter, multivariate analysis (backward logistic regression) revealed age≥75 years and recent/recurrent gastrointestinal (GI) bleeding as predictive factors of in-hospital bleeding BARC of any type (OR=2.14, 1.21-3.80 95% CIs, p=0.009 and OR=6.48, 1.13-37.2 95% CIs, p=0.04 respectively). In 215 propensity-matched pairs of patients, rate of in-hospital bleeding BARC of any type did not differ significantly between clopidogrel vs prasugrel or ticagrelor -treated patients (3.7% vs 7.9%, p=0.098). Conclusions: In a real-world PCI-treated ACS population, older age and previous GI bleeding are associated with an increased risk of low to moderate severity in-hospital bleeding events. A trend towards more bleeding with the newer agents is apparent.

Switching of P2Y12 inhibitor in patients with acute coronary syndrome: Insights from the GReek AntiPlatElet Registry (GRAPE)

Switching of P2Y12 inhibitor in patients with acute coronary syndrome: Insights from the GReek AntiPlatElet Registry (GRAPE)