Triple Antiplatelet Therapy Research Articles

Early Secondary Prevention in Transient Ischemic Attack (TIA) and Minor Stroke.

The purpose of this study was to review recent literature on the early secondary prevention in transient ischemic attack (TIA) and minor stroke. The result of Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events and the secondary analysis of Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) have shown that treatment with clopidogrel and aspirin for 21days reduced the risk of recurrent stroke with no significant increase in bleeding risk. Triple antiplatelet therapy with aspirin, clopidogrel, and dipyridamole resulted in a significant increase in major (including fatal) bleeding with no significant reduction in the recurrent stroke or TIA. The early treatment of patients with TIA or minor stroke with clopidogrel and aspirin for 21days was effective in reducing the risk of recurrent stroke with no significant increase in bleeding risk. Most stroke guidelines have been updated to reflect this recommendation.

The Dipyridamole Added to Dual Antiplatelet Therapy in Cerebral Infarction After First Acute Myocardial Infarction: A Nationwide, Case-Control Study.

Background and Purpose: No previous study has compared the impact of dipyridamole-based triple antiplatelet therapy on secondary stroke prevention and long-term outcomes to that of dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI) and previous stroke. This study aimed to evaluate the impact of dipyridamole added to DAPT on stroke prevention and long-term outcomes in patients with cerebral infarction after first AMI.Methods: This nationwide, case-control study included 75,789 patients with cerebral infarction after first AMI. A 1:4 propensity score matching ratio was adopted based on multiple variables. Finally, the data of 4,468 patients included in the DAPT group and 1,117 patients included in the Dipyridamole-DAPT group were analyzed. Primary outcome was overall survival. Secondary outcomes were cumulative event rate of recurrent MI or stroke, and cumulative intracerebral hemorrhage (ICH) and gastrointestinal bleeding rate.Results: Long-term survival rate was comparable between the two groups (log-rank P = 0.1117), regardless of sex analyses. However, after first year, DAPT subgroup revealed better survival over DAPT-dipyridamole subgroup (log-rank P = 0.0188). In age subgroup analysis, a lower survival rate was detected in younger patients from the Dipyridamole-DAPT group after first year (log-rank P = 0.0151), but no survival difference for older patients. No benefit of Dipyridamole-DAPT was detected for patients after AMI, regardless of the myocardial infarction type. DAPT was superior to Dipyridamole-DAPT in patients who underwent percutaneous coronary intervention (PCI) (log-rank P = 0.0153) and ST elevation myocardial infarction after first year (log-rank P = 0.0019). Dipyridamole-DAPT did not reduce cumulative event rate of recurrent MI or stroke in patients after AMI. Moreover, Dipyridamole-DAPT increased the cumulative ICH rate (log-rank P = 0.0026), but did not affect the cumulative event rate of gastrointestinal bleeding. In Cox analysis, dipyridamole did not improve long-term survival.Conclusions: This nationwide study showed that Dipyridamole-DAPT, compared with DAPT, did not improve long-term survival in patients with stroke after AMI, and was related to poor outcomes after 1 year. Dipyridamole-DAPT did not reduce recurrent rate of MI or stroke, but increased the ICH rate without impacting the incidence of gastrointestinal bleeding.

Triple versus dual antiplatelet therapy in patients with acute coronay syndrome undergoing percutaneous coronary intervention (PCI) in our center

Triple versus dual antiplatelet therapy in patients with acute coronay syndrome undergoing percutaneous coronary intervention (PCI) in our center

Effects of Cilostazol-Based Triple Antiplatelet Therapy Versus Dual Antiplatelet Therapy After Coronary Drug-Eluting Stent Implantation: An Updated Meta-Analysis of the Randomized Controlled Trials.

The results of studies on cilostazol-based triple antiplatelet therapy (TAT) after drug-eluting stent (DES) implantation were inconsistent. To assess the effects of TAT compared with dual antiplatelet therapy (DAT) after DES/second-generation DES implantation, we performed a meta-analysis of randomized controlled trials (RCTs). All relevant studies evaluated were identified by searching thePubMed, EMBASE, Cochrane Library, and ISI Web of Sciencedatabases without time and language limitation. Subgroup analyses were performed to evaluate the efficacy and safety of TAT after second-generation DES implantation. Eleven RCTs involving a total of 4684 patients were included. The meta-analysis showed TAT was associated with significant beneficial effects on angiographic findings of in-stent restenosis [risk ratio (RR) 0.645, 95% confidence interval (CI) 0.470-0.885; P = 0.007], in-segment restenosis (RR 0.606, 95% CI 0.450-0.817; P = 0.001), in-stent late loss (RR - 0.095, 95% CI - 0.136 to - 0.054; P < 0.0001), in-segment late loss (RR - 0.100, 95% CI - 0.139 to - 0.061; P < 0.0001), target lesion revascularization (TLR) (RR 0.570, 95% CI 0.430-0.755; P < 0.0001), and target vessel revascularization (TVR) (RR 0.523, 95% CI 0.380-0.719; P < 0.0001). No significant difference was found in outcomes of all-cause death, cardiac death, definite/probable stent thrombosis (ST), non-fatal myocardial infarction (MI), overall bleeding, and major bleeding between the two groups, as well as some minor adverse effects including palpitations, thrombocytopenia, neutropenia, and hepatic dysfunction. However, the incidence rate of rash, gastrointestinal disorders, and headache was significantly higher in TAT. The second-generation DES subgroup showed similar results, except for the indicators of all-cause death (RR 2.161, 95% CI 1.007-4.635; P = 0.048) and hepatic dysfunction (RR 0.176, 95% CI 0.031-0.995; P = 0.049). Compared with DAT, cilostazol-based TAT can significantly improve the angiographic findings of in-stent and in-segment late loss, in-stent and in-segment restenosis, TLR, and TVR after DES/second-generation DES implantation. However, no benefits were observed in outcomes of all-cause death, cardiac death, ST, and MI.

Adverse clinical outcomes associated with double dose clopidogrel compared to the other antiplatelet regimens in patients with coronary artery disease: a systematic review and meta-analysis

BackgroundRecently, several newer antiplatelet treatment strategies have been used in patients with coronary artery disease (CAD). Apart from the dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel, double dose clopidogrel (DDC), triple antiplatelet therapy (TAPT) consisting of aspirin, clopidogrel and cilostazol and other newer antiplatelet agents have shown to be effective in different ways. In this analysis, we aimed to systematically compare the adverse clinical outcomes and the bleeding events which were observed when DDC was compared to the other antiplatelet regimens in patients with CAD.MethodsEnglish publications comparing DDC with other antiplatelet regimens were searched from MEDLARS/MEDLINE, EMBASE, www.ClinicalTrials.gov and Google Scholar. Adverse cardiovascular outcomes and bleeding events were the study endpoints. Statistical analysis was carried out by the RevMan 5.3 software whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated.ResultsA total number of 23,065 participants were included. Results of this analysis showed major adverse cardiac events (MACEs), all-cause mortality, cardiac death, stroke, stent thrombosis, revascularization and myocardial infarction (MI) to have been similarly manifested in patients who were treated with DDC versus the control group with OR: 0.98, 95% CI: 0.78–1.22; p = 0.83, OR: 0.95, 95% CI: 0.77–1.17; p = 0.62, OR: 0.97, 95% CI: 0.79–1.20; p = 0.81, OR: 0.98, 95% CI: 0.65–1.48; p = 0.94, OR: 0.84, 95% CI: 0.40–1.75; p = 0.64, OR: 0.88, 95% CI: 0.52–1.49; p = 0.63, and OR: 0.89, 95% CI: 0.65–1.21; p = 0.45 respectively. Any minor and major bleedings were also similarly manifested.When DDC was compared to DAPT, no significant difference was observed in any bleeding event with OR: 1.58, 95% CI: 0.86–2.91; p = 0.14. Even when DDC was compared with either ticagrelor or prasugrel or TAPT, still no significant difference was observed in terms of bleeding outcomes.ConclusionsIn patients with CAD, adverse clinical outcomes were not significantly different when DDC was compared to the other antiplatelet regimens. In addition, bleeding events were also similarly manifested when DDC was compared to DAPT, TAPT or ticagrelor/prasugrel.

The safety of triple antiplatelet therapy under thromboelastography guidance in patients undergoing stenting for ischemic cerebrovascular disease

ObjectiveTo investigate the safety of triple antiplatelet therapy (TAT) with cilostazol in patients undergoing stenting for extracranial and/or intracranial artery stenosis.MethodsA prospectively collected database was reviewed to identify patients who...

Combination of Unfractionated Heparin (UFH) and Triple Antiplatelet Therapy After Percutaneous Coronary Intervention (PCI) May Increase the Risk of Life Threatening Hemothorax in a Patient with Recent Rib Fracture

Combination of Unfractionated Heparin (UFH) and Triple Antiplatelet Therapy After Percutaneous Coronary Intervention (PCI) May Increase the Risk of Life Threatening Hemothorax in a Patient with Recent Rib Fracture

Antiplatelet therapy after stroke: should it differ in the acute and chronic phase after stroke.

Reviewing existing evidence regarding well tolerated and effective antiplatelet treatment in patients with acute or chronic, noncardioembolic ischemic stroke and transient ischemic attack (TIA). For patients with high-risk stroke or TIA, for instance, minor stroke or high-risk TIA, or stroke of atherosclerotic origin with evidence suggesting risk of artery-to-artery embolism or with high-grade, symptomatic arterial stenosis, early initiated, short-term dual antiplatelet (e.g. aspirin and clopidogrel) is effective in reducing the risk of recurrent stroke and other vascular events which does not increase the risk of severe or fatal bleeding, as compared with mono antiplatelet therapy. However, long-term application of aggressive antiplatelet therapies after a noncardioembolic stroke or TIA increases the bleeding risks. Triple antiplatelet therapy is not appropriate for noncardioembolic stroke or TIA, in view of the high bleeding risk. In addition, emerging antiplatelets such as ticagrelor and cilostazol may work better in certain subgroups of stroke patients, which warrants further investigation. Antiplatelet therapies should differ in the acute and chronic phases among patients with high-risk stroke or TIA when more aggressive antiplatelet treatment is reasonable in the acute phase, but no solid evidence supports different antiplatelet strategies in acute and chronic phases in patients with low-risk noncardioembolic stroke.

Designing Natural Product Hybrids Bearing Triple Antiplatelet Profile and Evaluating Their Human Plasma Stability.

Cardiovascular diseases (CVDs) are becoming major contributors to the burden of disease due to genetic and environmental factors. Despite current standard oral care, cardiovascular risk remains relatively high. A triple antiplatelet therapy with a cyclooxygenase-1 (COX-1) inhibitor, a P2Y12 receptor antagonist, and a protease-activated receptor-1 (PAR-1) antagonist has been established in the secondary prevention of atherothrombosis in patients with acute myocardial infraction and in those with peripheral artery disease. However, due to the combinatorial use of three different drugs, patients receiving this triple therapy are exposed to enhanced risk of bleeding. Conforming to polypharmacology principles, the discovery of a single compound that can simultaneously block the three platelet activation pathways (PAR-1, P2Y12, and COX-1) is of importance. Natural products have served as an inexhaustiblesource of bioactive compounds presenting a diverse pharmaceutical profile, including anti-inflammatory, antioxidant, anticancer, and antithrombotic activity. Indeed, principal component analysis indicated that natural products have the potential to inhibit the three aforementioned pathways, though existed reports refer to single inhibition mechanism on specific receptor(s) implicated in platelet activation. We thus set out to explore possibilities thattake advantage of this potential of natural products and shape the basis to produce novel compounds that could simultaneously target PAR-1, P2Y12, and COX-1 platelet activation pathways. Polyunsaturated fatty acids (PUFAs) have multiple effects leading to improvements in blood pressure and cardiac function and arterial compliance. A promising approach to achieve the desirable goal is the bioconjugation of natural products with PUFAs. Herein, we describe the principles that should be followed to develop molecular hybrids bearing triple antiplatelet activity profile.

Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

SummaryBackgroundIntensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy.MethodsWe did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388.Findings3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67–1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05–3·16, p<0·0001).InterpretationAmong patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice.FundingNational Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.

Recent Evolution of the Treatment of Coronary Artery Disease in China: A Conversation With Ya-Ling Han, MD, PhD.

Ya-Ling Han, MD, PhD, was born in Wuhan, Hubei province, in 1953. She graduated from Haebin Medical University in 1978. She received her doctorate in 1994 from Shanghai Second Military Medical University. She was a visiting scholar at the National Heart Center, Singapore. She is currently a professor and the director of the Department of Cardiology, General Hospital of Shenyang Military Region; the director of the Cardiovascular Research Institute; and the director of the Key Laboratory of Acute Severe Cardiovascular Treatment Research of the Chinese People’s Liberation Army. She is the president of the Chinese College of Cardiovascular Physicians and Chairperson-elect of the Chinese Society of Cardiology. Dr Rutherford asks: Could you describe the scope of clinical cardiac care provided in the Department of Cardiology at the General Hospital of Shenyang Military Region? Dr Ya-L ing Han replies : The Department of Cardiology at the General Hospital of Shenyang Military Region, together with the departments of congenital heart disease and cardiovascular surgery, constitute the cardiovascular institute of the People’s Liberation Army, which is among the top 5 centers in China providing comprehensive care for CVD. Our center is located in Northeast China, an area with the highest prevalence of CAD, so the treatment and prevention of CAD is our major focus. We are a busy center: we perform ≈7000 PCIs, 1400 radiofrequency ablations, 550 pacemaker implantations, 900 congenital heart disease interventions, and ≈2500 cardiovascular surgeries annually, with an overall in-hospital mortality rate of <1%. We have pioneered many facets of CVD treatment in China, including PCI for complicated coronary lesions, CTO of coronary arteries, left main coronary disease, treatment of high-risk patients with AMI, novel antithrombotic strategies for coronary patients, and surgical and percutaneous treatment of complicated congenital heart disease. Over the past 2 decades, you and your team have …

Comparison of 1-Year Outcomes of Triple (Aspirin + Clopidogrel + Cilostazol) Versus Dual Antiplatelet Therapy (Aspirin + Clopidogrel + Placebo) After Implantation of Second-Generation Drug-Eluting Stents into One or More Coronary Arteries: from the DECREASE-PCI Trial

This study sought to evaluate the impact of triple antiplatelet therapy on clinical outcomes in patients treated with second-generation drug-eluting stents (DES) for coronary artery disease. There are limited data regarding the impact of triple antiplatelet therapy in patients who underwent implantation of second-generation DES. We planned to randomly assign 2,110 patients treated with second-generation DES to triple (aspirin, clopidogrel, and cilostazol) and dual (aspirin, clopidogrel, and placebo) antiplatelet therapy groups. The primary end point was a composite of death, myocardial infarction, ischemic stroke, or target vessel revascularization (TVR) at 1 year since randomization. The study was stopped early owing to slow enrollment. In total, 404 patients (202 patients each in the triple and dual antiplatelet therapy groups) were finally enrolled. At 1 year, the primary end point had occurred in 3.6% and 9.4% of patients in the triple and dual antiplatelet therapy groups, respectively (hazard ratio [HR] of the triple group 0.396; 95% confidence interval [CI] 0.166 to 0.949; p = 0.038). There was no significant difference between the 2 groups regarding the occurrence of a composite of all-cause death, myocardial infarction, or ischemic stroke (HR 0.583; 95% CI 0.229 to 1.481; p = 0.256). However, the rates of TVR were significantly lower in the triple antiplatelet therapy group than in the dual antiplatelet therapy group (HR 0.118; 95% CI 0.015 to 0.930; p = 0.043). In conclusion, triple antiplatelet therapy with cilostazol after implantation of second-generation DES improved clinical outcomes, mainly by reducing TVR.

Triple Therapy Versus Dual Antiplatelet Therapy for Patients with Atrial Fibrillation and Acute Coronary Syndromes: A Systematic Literature Review.

Background: Patients with acute coronary syndromes (ACS) and a history of atrial fibril-lation (AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines. We examined studies comparing clinical outcomes on DAPT versus TT for patients with AF and ACS.Methods: We searched Medline, Medline pending, EMBASE and Evidence-Based Medicine Re-views databases for studies published between January 2000 to December 2016 in AF patients with ACS that compared DAPT and TT that reported ischaemic and/or bleeding outcomes. Studies that were not purely an AF population were excluded.Results: Ten studies were included in the review, all of which were observational, 8 of which were retrospective. None of the studies detailed the specifics of treatment allocation. All but one were of AF patients with a mix of stable coronary disease and ACS patients. TT was associated with in-creased bleeding when compared to DAPT, with adjusted odds ratios ranging from 1.25 to 6.84. While the largest study reported a reduction in stroke associated with TT (odds ratio 0.67), two other studies reported non-significant increases in stroke with TT. Variable composite ischaemic endpoints were reported, none showing a statistical significant difference between DAPT and TT.Conclusion: In patients with ACS and AF, TT is likely to be associated with increased risk of bleed-ing, without a clear reduction in ischaemic endpoints. The quality of the evidence to support current guidelines for this patient group was generally poor.

Tailoring naringenin conjugates with amplified and triple antiplatelet activity profile: Rational design, synthesis, human plasma stability and in vitro evaluation

BackgroundThe current standard-of-care antiplatelet therapy in cardiovascular disease patients is consisted of cyclooxygenase-1 (COX-1) inhibitor aspirin, along with a platelet receptor P2Y12 antagonist. Recently, the triple antiplatelet therapy with aspirin, a P2Y12 receptor antagonist and a protease activated receptor-1 (PAR-1) antagonist, has been suggested for the secondary prevention of atherothrombotic events, however presented an increased risk of bleeding. Therefore, the quest for novel antiplatelet agents simultaneously targeting the three pathways with improved efficacy/safety profile is of immense importance. Flavonoids as pre-validated ligands for numerous targets could serve as scaffolds targeting the three platelet activation pathways. MethodsComputational methods, Ultra High Performance Liquid Chromatography-Tandem Mass Spectrometry (UHPLC-MS/MS) plasma stability and in vitro platelet aggregation experiments were used to establish the antiplatelet activity of the flavonoid naringenin and its conjugates. ResultsIn silico studies indicated that naringenin could bear a potent triple antiplatelet activity by inhibiting different platelet aggregation mechanisms. However, we found that in human platelets naringenin has diminished activity. We rationally designed and synthesized different naringenin conjugates aiming to amplify the antiplatelet activity of the parent compound. UHPLC-MS/MS revealed a slow degradation rate for a docosahexaenoic acid (DHA) – naringenin conjugate in human plasma. The antiplatelet profile of the new analogues was evaluated against in vitro platelet aggregation induced by several platelet agonists. ConclusionsThe DHA – naringenin hybrid presented triple antiplatelet activity simultaneously targeting PAR-1, P2Y12 and COX-1 platelet activation pathways. General significanceNatural products could offer a rich source for novel bioactives as a powerful alternative to the current combinatorial use of three different antiplatelet drugs.

The Risk of Bleeding in Triple Antiplatelet Therapy: Cilostazol Added to Aspirin and Clopidogrel for Coronary Artery Disease Patients Who Underwent Percutaneous Coronary Intervention: A Meta-Analysis Study of Randomized Controlled Trials

BACKGROUND: A novel cilostazol-based triple antiplatelet therapy (TAT) was shown in a trial to have a lower restenosis rate than the usual clopidogrel and aspirin dual antiplatelet therapy (DAPT) among patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention. However, TAT may also be associated with an increased risk of bleeding. A systematic review would show further evidence regarding the risk of bleeding among TAT-treated patients. MAIN OBJECTIVE: To determine the risk of bleeding with TAT composed of cilostazol, aspirin and clopidogrel for CAD patients who underwent percutaneous coronary intervention. METHODS: This systematic review included randomized controlled trials (RCT) published from 2005 to 2014. Only one study was blinded. These studies compared the risk of major bleeding between DAPT and TAT. Meta-analysis of this outcome was conducted using Review Manager (RevMan) Version 5.3 2014. RESULTS: The overall relative risk (RR) of major bleeding in TAT patients was 1.23 (CI 95% 0.90, 1.67; z=1.30, p=0.19). The heterogeneity of results of the seven studies was not statistically significant (p=0.88; I2=0%). When isolating those studies with favorable outcome with TAT, the risk of bleeding demonstrated in five studies was also not statistically significant (p=0.11; I2=0%). Sensitivity analysis on two studies with wider deviation and slightly lower rates of bleeding showed no significant influence on the risk of bleeding (RR 0.78; CI 0.29, 2.09; p=0.63; I2=0%). CONCLUSION: Compared with DAPT, the trend towards increased major bleeding in cilostazol -based TAT did not reach statistical significance.

Impact of a modified anti-thrombotic guideline on stroke in children supported with a pediatric ventricular assist device

Stroke is the most feared complication associated with the Berlin Heart EXCOR pediatric ventricular assist device (VAD), the most commonly used VAD in children, and affects 1 in 3 children. We sought to determine whether a modified anti-thrombotic guideline, involving more intense platelet inhibition and less reliance on platelet function testing, is associated with a lower incidence of stroke. All children supported with the EXCOR at Stanford from 2009 to 2014 were divided into 2 cohorts based on the primary anti-thrombotic guideline used to prevent pump thrombosis: (1) the Edmonton Anti-thrombotic Guideline (EG) cohort, which included children implanted before September 2012 when dual anti-platelet therapy was used with doses titrated to Thromboelastrography/PlateletMapping (TEG/PM); and (2) the Stanford Modified Anti-thrombotic Guideline (SG) cohort, which included children implanted on or after September 2012 when triple anti-platelet therapy was used routinely and where doses were uptitrated to high, weight-based dosing targets, with low-dose steroids administered as needed for inflammation. At baseline, the EG (N = 16) and SG (N = 11) cohorts were similar. The incidence rate of stroke in the SG cohort was 84% lower than in the EG cohort (0.8 vs 4.9 events per 1,000 days of support, p = 0.031), and 86% lower than in the previous Investigational Device Exemption trial (p = 0.006). The bleeding rate was also lower in the SG cohort (p = 0.015). Target doses of aspirin, clopidogrel and dipyridamole were higher (all p < 0.003), with less dosing variability in the SG cohort than in the EG cohort. There was no difference in adenosine diphosphate inhibition by TEG/PM, but arachidonic acid inhibition was higher in the SG cohort (median 75% vs 39%, p = 0.008). Stroke was significantly less common in pediatric patients supported with the Berlin Heart EXCOR VAD using a triple anti-platelet regimen uptitrated to high, weight-based dosing targets as compared with the dual anti-platelet regimen titrated to PM, and without a higher risk of bleeding. Larger studies are needed to confirm these findings.

Outcome of Triple Antiplatelet Therapy Including Cilostazol in Elderly Patients with ST-Elevation Myocardial Infarction who Underwent Primary Percutaneous Coronary Intervention: Results from the INTERSTELLAR Registry.

Compared with dual antiplatelet therapy including aspirin and clopidogrel, triple antiplatelet therapy including cilostazol has a mortality benefit in patients with ST-segment elevation myocardial infarction. However, whether the mortality benefit persists in elderly patients is not clear. From 2007 to 2014, 1278 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were retrospectively analyzed. The patients were divided into four groups by age (<75 or ≥75years; young and elderly, respectively) and antiplatelet strategy (triple or dual antiplatelet therapy). We compared the mortality rates between the triple and dual antiplatelet therapy groups. There were 1052 (male, 85%; mean age, 56.3±10.4years) patients in the young group and 241 (male, 52.7%; mean age, 80.3±4.5years) patients in the elderly group. In the young and elderly groups, 220 (20.9%) and 28 (12.3%) patients were treated with triple antiplatelet therapy. During a 1-year follow-up period, 80 patients died (4.2% in the young group vs. 15.5% in the elderly group). Kaplan-Meier survival analysis revealed that triple antiplatelet therapy was associated with a lower mortality rate in the young group (log-rank, p=0.005). Although there were more angiographic high-risk patients in the elderly group, similar mortality rates were reported (log-rank, p=0.803) without increased bleeding rates (1 vs. 3.6% in the elderly group, p=0.217). Triple antiplatelet therapy might be a better antiplatelet regimen than dual antiplatelet therapy for patients with ST-segment elevation myocardial infarction. Although this benefit was strong in patients aged <75years, no definite increase in major bleeding was seen for elderly patients (aged ≥75years).

Sarpogrelate Based Triple Antiplatelet Therapy Improved Left Ventricular Systolic Function in Acute Myocardial Infarction: Retrospective Study.

PurposeThe purpose of this study was to assess the potential benefit of a 5-hydroxytryptamine receptor antagonist, sarpogrelate-based triple antiplatelet therapy (TAPT) in comparison with dual antiplatelet therapy (DAPT) in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).Materials and Methods119 patients of STEMI were retrospectively assessed. All patients received aspirin and clopidogrel per standard of care. Among them, 53 patients received an additional loading dose of sarpogrelate and a maintenance dose for 6 months post-PCI (TAPT group), while others did not (DAPT group).ResultsThe rates of complete ST-segment resolution at 30 minutes post-PCI and post-procedural thrombolysis in myocardial infarction flow were not significantly different between the two groups (52.8% vs. 48.5%, p=0.200; 92.5% vs. 89.4%, p=0.080). In addition, no significant differences were observed between the two groups with regard to 30-day and 12-month clinical outcomes (cardiac death, myocardial infarction, stent thrombosis, target vessel revascularization, and severe bleeding). Meanwhile, improvement in left ventricular (LV) systolic function was observed in the TAPT group [ΔLV ejection fraction (LVEF)=17.1±9.4%, p<0.001; Δglobal longitudinal strain (GLS)=−9.4±4.2% , p<0.001] at 6 months, whereas it was not in the DAPT group (ΔLVEF= 8.8±6.5%, p=0.090; ΔGLS=−4.6±3.4%, p=0.106). In multivariate analyses, TAPT was an independent predictor for LV functional recovery (odds ratio, 2.61; 95% confidence interval, 1.16–5.87; p=0.003).ConclusionSarpogrelate-based TAPT improved LV systolic function at 6 months in STEMI patients undergoing primary PCI.

Differences in the Korea Acute Myocardial Infarction Registry Compared with Western Registries.

The Korea Acute Myocardial Infarction Registry (KAMIR) is the first nationwide registry that reflects current therapeutic approaches and acute myocardial infarction (AMI) management in Korea. The results of the KAMIR demonstrated different risk factors and responses to medical and interventional treatments. The results indicated that the incidence of ST-elevation myocardial infarction (STEMI) was relatively high, and that the prevalence of dyslipidemia was relatively low with higher triglyceride and lower high-density lipoprotein cholesterol levels. Percutaneous coronary intervention (PCI) rates were high for both STEMI and non-ST-elevation myocardial infarction (NSTEMI) with higher use of drug-eluting stents (DESs). DES were effective and safe without increased risk of stent thrombosis in Korean AMI patients. Triple antiplatelet therapy, consisting of aspirin, clopidogrel, and cilostazol, was effective in preventing adverse clinical outcomes after PCI. Statin therapy was effective in Korean AMI patients, including those with very low levels of low-density lipoprotein cholesterol and those with cardiogenic shock. The KAMIR score had a greater predictive value than Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores for long-term mortality in AMI patients. Based on these results, the KAMIR will be instrumental for establishing new therapeutic strategies and effective methods for secondary prevention of AMI and guidelines for Asian patients.

Recent Update of Korea Acute Myocardial Infarction Registry (KAMIR)

Korea Acute Myocardial Infarction Registry (KAMIR) is the first nationwide registry and reflects the current therapeutic approaches and management for acute myocardial infarction (AMI) in Korea. The results of KAMIR demonstrated different risk factors and different responses to medical and interventional therapies. The prevalence of hypertension, diabetes mellitus and dyslipidemia has increased, but smoking has decreased remarkably. Different pattern of dyslipidemia was demonstrated. The KAMIR score was better than TIMI and GRACE scores in the prediction of long-term mortality in AMI patients. Triple antiplatelet therapy, consisting of aspirin, clopidogrel and cilostazol, was effective in preventing adverse clinical outcomes after percutaneous coronary intervention (PCI). Prasugrel and ticagrelor could not reduce ischemic events, but increased bleeding risk in Korean patients. Therefore, we may recommend low dose prasugrel and ticagrelor compared with Western patients. Statin therapy was effective in Korean AMI patients, including those with very low levels of low density cholesterol and spasm-induced AMI. Statin and ezetimibe was effective in high-risk AMI patients, such as diabetes, old age and systolic heart failure. PCI and its success rates of ST-elevation myocardial infarction (STEMI) are 96.7% and 99.4%, and those of non-ST-elevation myocardial infarction (NSTEMI) 82.7% and 99.5%, respectively. Drug-eluting stents were effective and safe in AMI patients with no increased risk of stent thrombosis in Korean patients. KAMIR will provide new therapeutic strategies and effective methods for secondary prevention of AMI and new guidelines for Asian patients.