Use Of New Antiplatelet Agents Research Articles

"Impact of age on management and prognosis of resuscitated sudden cardiac death patients".

Sudden cardiac death (SCD) has a great impact on healthcare due to cardiologic and neurological complications. Admissions of elderly people in Cardiology Intensive Care Units have increased. We assessed the impact of age in presentation, therapeutic management and in vital and neurological prognosis of SCD patients. We carried out a retrospective, observational, multicenter registry of patients who were admitted with a SCD in 5 tertiary hospitals from January 2013 to December 2020. We divided our cohort into two groups (patients<80years and≥80years). Clinical, analytical and hemodynamic variables as well as in-hospital management were registered and compared between groups. The degree of neurological dysfunction, vital status at discharge and the influence of age on them were also reviewed. We reviewed 1160 patients admitted with a SCD. 11.3% were≥80years. Use of new antiplatelet agents, performance of a coronary angiography, use of pulmonary artery catheter and temperature control were less carried out in the elderly. Age, non-shockable rhythm, Killip class>1 at admission, time to CPR initiation>5min, time to ROSC>20min and lactate>2mmol/L were independent predictors for in-hospital mortality. Non-shockable rhythm, Killip class>1 at admission, time to CPR initiation>5min and time to ROSC>20min but not age were independent predictors for poor neurological outcomes. Age determined a less aggressive management and it was associated with a worse vital prognosis in patients admitted with a SCD. Nevertheless, age was not associated with worse neurological outcomes.

Intracranial Hemorrhage After Reperfusion Therapies in Acute Ischemic Stroke Patients.

Reperfusion therapies are the mainstay of acute ischemic stroke (AIS) treatments and overall improve functional outcome. Among the established complications of intravenous (IV) tissue-type plasminogen activator (tPA), intracranial hemorrhage (ICH) is by far the most feared and has been extensively described by seminal works over the last two decades. Indeed, IV tPA is associated with increased odds of any ICH and symptomatic ICH responsible for increased mortality rate during the first week after an AIS. Despite these results, IV tPA has been found beneficial in several pioneering randomized trials and improves functional outcome at 3 months. Endovascular therapy (EVT) combined with IV tPA for AIS patients consecutive to an anterior circulation large-vessel occlusion does not increase ICH occurrence. Of note, EVT following IV tPA leads to significantly higher rates of early reperfusion than with IV tPA alone, with no difference in ICH, which challenges the paradigm of reperfusion as a major prognostic factor for ICH complications. However, several blood biomarkers (glycemia, platelet and neutrophil count), clinical factors (age, AIS severity, blood pressure management, diabetes mellitus), and neuroradiological factors (cerebral microbleeds, infarct size) have been identified as risk factors for ICH after reperfusion therapy. In the years to come, the ultimate goal will be to further improve either reperfusion rates and functional outcome, while reducing hemorrhagic complications. To this end, various approaches being investigated are discussed in this review, such as blood-pressure control after reperfusion or the use of new antiplatelet agents as an adjunct to IV tPA and exhibit reduced hemorrhagic potential during the early phase of AIS.

Australian Trends in Procedural Characteristics and Outcomes in Patients Undergoing Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Over the last decade, systems of care for ST-elevation myocardial infarction (STEMI) have evolved to try to improve outcomes and timely access to percutaneous coronary intervention (PCI). There have also been advances in PCI techniques and adjunctive pharmacotherapies. In this study, we sought to determine temporal changes in practices and clinical outcomes of PCI in patients with STEMI. We prospectively collected data on 8,412 consecutive patients undergoing PCI for STEMI between 2005 and 2016 in the multicenter Melbourne Interventional Group registry. Data were divided by procedure year for trends analysis. The primary end point was 30-day mortality. Patient demographics and comorbidities including smoking and diabetes have remained stable. The volume of primary PCI performed within 12 hours of symptom onset has significantly risen (65.7% to 80.1%, p < 0.01). The proportion of patients achieving the recommended door-to-balloon time ≤90 minutes has also risen (37.6% to 59.0%, p < 0.01). Patient complexity has also increased with more patients after out-of-hospital cardiac arrest with STEMI now being treated with PCI (2.6% to 9.1%, p < 0.01). A shift from mainly femoral to radial access and from bare-metal to drug-eluting stent use was seen. Glycoprotein IIb/IIIa inhibitors are being used less frequently with increasing use of newer antiplatelet agents. Thirty-day mortality has remained low throughout the study period at 6.5% overall. In conclusion, although timely access to primary PCI has improved, mortality rates have remained unchanged, but remain low and compare favorably with international data. Australian PCI practice has overall evolved in response to evidence and emergence of new adjunctive device and pharmacotherapies.

Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a “Real World” Multicenter Registry

Introduction and objectivesThe incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the “real world” remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). MethodsA multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. ResultsThe study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). ConclusionsIn a “real world” setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.

Seguridad y eficacia clínica con prasugrel y ticagrelor en síndrome coronario agudo. Resultados de un registro multicéntrico en el mundo real

Introduction and objectivesThe incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the “real world” remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). MethodsA multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. ResultsThe study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). ConclusionsIn a “real world” setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.Full English text available from:www.revespcardiol.org/en

The Use Pattern and Clinical Impact of New Antiplatelet Agents Including Prasugrel and Ticagrelor on 30-day Outcomes after Acute Myocardial Infarction in Korea: Korean Health Insurance Review and Assessment Data.

Background and ObjectivesDespite the favorable efficacy of new antiplatelet agents demonstrated in randomized controlled trials, their clinical implications in Korea are unclear. The purpose of this study was to investigate trends in antiplatelet agent use for acute myocardial infarction (AMI) and their impact on 30-day clinical outcomes.MethodsAMI patients undergoing percutaneous coronary intervention between 2010 and 2015 were assessed using claim data from the Health Insurance Review and Assessment Service.ResultsThe use of new antiplatelet agents has rapidly increased since 2013 and has been preferred over clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals) since 2015. Both prasugrel (Effient; Eli Lilly and Company) (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.31–0.67; p<0.001) and ticagrelor (Brilinta; AstraZeneca Pharmaceuticals LP) (OR, 0.84; 95% CI, 0.71–0.98; p=0.032) had an independent effect on lowering 30-day mortality in a weighted multivariable logistic regression model. However, new antiplatelet agents had no significant effect on other clinical outcomes including myocardial infarction, stroke, bleeding, and readmission within 30 days.ConclusionThe use of new antiplatelet agents is rapidly increasing, and they have been used more commonly than clopidogrel since 2015. We demonstrated that new antiplatelet agents have a favorable effect on reducing 30-day mortality in AMI patients in Korea.

Personalized antiplatelet therapy with P2Y12 receptor inhibitors: benefits and pitfalls.

Antiplatelet therapy with P2Y12 receptor inhibitors has become the cornerstone of medical treatment in patients with acute coronary syndrome, after percutaneous coronary intervention and in secondary prevention of atherothrombotic events. Clopidogrel used to be the most broadly prescribed P2Y12 receptor inhibitor with undisputable benefits especially in combination with aspirin, but a considerable number of clopidogrel-treated patients experience adverse thrombotic events in whom insufficient P2Y12-inhibition and a consequential high on-treatment platelet reactivity is a common finding. This clinically relevant limitation of clopidogrel has driven the increased use of new antiplatelet agents. Prasugrel (a third generation thienopyridine) and ticagrelor (a cyclopentyl-triazolo-pyrimidine) feature more potent and predictable P2Y12-inhibition compared to clopidogrel, which translates into improved ischemic outcomes. However, excessive platelet inhibition and consequential low on-treatment platelet reactivity comes at the price of increased risk of major bleeding. The majority of randomized clinical trials failed to demonstrate improved clinical outcomes with platelet function testing and tailored antiplatelet therapy, but results of all recent trials of potent antiplatelets and prolonged antiplatelet durations point towards a need for individualized antiplatelet approach in order to decrease thrombotic events without increasing bleeding. This review focuses on potential strategies for personalizing antiplatelet treatment.

PM157 “Use of New Antiplatelet Agents in Patients with Acute Coronary Syndrome in the real word”

PM157 “Use of New Antiplatelet Agents in Patients with Acute Coronary Syndrome in the real word”

Role of Novel and Emerging Oral Anticoagulants for Secondary Prevention of Acute Coronary Syndromes

Dual antiplatelet therapy has become a mainstay of long-term management of patients after an acute coronary syndrome (ACS). Mortality for these patients remains high despite current evidence-based treatment strategies. The coagulation cascade plays a role in the pathophysiology of ACS, and trials with warfarin in combination with dual antiplatelet therapy have found decreased rates of ischemic events at the expense of increased bleeding risk. Novel oral anticoagulants (NOACs) in the direct factor Xa (FXa) inhibitor and direct thrombin inhibitor (DTI) categories have been evaluated in combination with standard post-ACS therapy. Rivaroxaban, a FXa inhibitor, reduced the rates of ischemic events but increased major bleeding rates. Apixaban did not decrease the rates of ischemic events and also increased major bleeding rates. Other FXa inhibitors have not been studied in the long-term management of ACS (e.g., otamixaban), are not currently being studied in ongoing phase III trials (e.g., TAK-442), or have been discontinued by the manufacturer (e.g., darexaban). The DTI dabigatran had a 2- to 4-fold increased risk of major bleeding with unclear benefit for reducing ischemic events. The factor IXa inhibitor pegnivacogin is an RNA-based aptamer that has been studied in patients undergoing cardiac catheterization but has not been studied for long-term post-ACS management. The European Society of Cardiology Working Group on Thrombosis recommends the use of newer antiplatelet agents over addition of NOACs. Additional guidelines are available to guide management in patients requiring triple antithrombotic therapy but do not provide definitive recommendations on NOACs. Many questions remain about the place of NOACs for long-term post-ACS management. Recent trials have evaluated double versus triple antithrombotic therapy to balance efficacy and bleeding risk, but they did not include NOACs. It also remains unclear if NOACs hold a place in post-ACS therapy in the era of more potent antiplatelet agents such as prasugrel and ticagrelor.

Abstract 63: Hospital Length of Stay after Percutaneous Coronary Intervention among Acute Coronary Syndrome Patients Treated with Clopidogrel or Prasugrel in a United States Hospital Database

Background: Research on the use of newer antiplatelet agents and their outcomes from a real-world setting is scarce. Hospital length of stay (LOS) has been used as a measure for resource use and as a proxy for patient outcomes. We analyzed a large geographically diverse database from the US and compared LOS between patients on clopidogrel or prasugrel. Patients were hospitalized for acute coronary syndrome (ACS) and had undergone percutaneous coronary intervention (PCI). Methods: Using a large database maintained by PREMIER, Inc., we analyzed patient characteristics and LOS during the index (first) hospitalization among ACS-PCI patients treated with clopidogrel or prasugrel between July 2009 and June 2011. Observed LOS was analyzed with t-tests. A multivariate regression model with a negative binomial distribution was used to evaluate differences in LOS, adjusting for the following covariates: age, ACS type (non-ST-elevation myocardial infarction [NSTEMI], STEMI, Unstable Angina [UA]), gender, race, renal insufficiency, diabetes, anemia, heart failure, number of vessels, bleeding events, and comorbidities based on the Charlson-Deyo weighting of disease states. Results: Data were available for 75,315 patients who received clopidogrel and 9,483 patients with prasugrel. For clopidogrel and prasugrel, respectively, the observed mean LOS (SD) was 3.5 (4.4) days and 2.9 (2.4) days (P&lt;0.0001) for the overall study population, and 4.0 (5.2) days and 3.3 (2.4) days for STEMI (P&lt;0.0001), 3.9 (4.6) days and 2.9 (2.5) days for NSTEMI (P&lt;0.0001), and 2.5 (2.4) days and 2.1 (1.8) days for UA (P&lt;0.0001). The overall adjusted LOS results similarly showed statistically significantly shorter LOS for prasugrel-treated patients than clopidogrel-treated patients. Conclusion: In this study, prasugrel- treated patients had a shorter average LOS compared to clopidogrel-treated patients. After adjusting for patient demographics and clinical characteristics, the results still held. The unobserved confounder bias, however, may exist in this real-world observational database research.

The treatment of clopidogrel resistance: Triple antiplatelet therapy and future directions

Despite the clinical benefit achieved with the adjunct of clopidogrel in percutaneous coronary intervention, a considerable number of patients continue to have cardiovascular events. There are accumulating evidences that recurrence of ischemic complications may be attributed to poor response to clopidogrel. However, current therapeutic alternatives for treatment of clopidogrel resistance remain limited. More aggressive intervention with higher doses of clopidogrel and the use of newer antiplatelet agents may help overcome resistance to antiplatelet agents.