Dyspnea in patients treated with P2Y12 receptor antagonists: insights from the GReek AntiPlatElet (GRAPE) registry.

In 'real life' acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) and receiving contemporary antiplatelet treatment, data on dyspnea occurrence and impact on persistence with treatment are scarce. In a prospective, multicenter, cohort study, ACS patients undergoing PCI were recruited into the GReekAntiPlatElet (GRAPE) registry. During 1-year follow up, overall, 249/1989 (12.5%) patients reported dyspnea, more frequently at 1-month and decreasing thereafter. Multivariate analysis showed that ticagrelor administration (n = 738) at discharge was associated with the occurrence of dyspnea: Odds ratio 2.46 (95% confidence interval, CI, 1.87-3.25), p < 0.001. Older age, lower hematocrit, and prior bleeding event were also associated with dyspnea reports. Persistence, switching, and cessation rates were 68.3%, 20.9%, and 10.8% vs 76.7%, 12.5%, and 10.9% among patients reporting dyspnea compared with those who did not, p for trend = 0.002. In conclusion, in ACS patients undergoing PCI and treated with a P2Y12 receptor antagonist, dyspnea occurs commonly, particularly when ticagrelor is administered. Non-persistence with antiplatelet agents at discharge is more frequently observed among dyspnea-reporters.

Ticagrelor vs clopidogrel followed by ticagrelor re-loading in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A randomized, pharmacodynamic comparison.

Among patients allocated to ticagrelor in the primary percutaneous coronary intervention (PCI) cohort of Platelet Inhibition and Patient Outcomes (PLATO) trial, 40.7% had received pre-randomization 600 mg of clopidogrel. This scenario is frequently employed in real-world practice. In a prospective, three-center, single-blind, parallel design study, 74 P2Y12 inhibitor-naive patients undergoing primary PCI were randomized (Hour 0) to ticagrelor 180 mg loading dose (LD) vs clopidogrel 600 mg LD followed after 2 h by ticagrelor 180 mg re-LD. Platelet reactivity (VerifyNow, in PRU) was assessed at Hour 0, 2, 4, 6, and 24. The primary comparison was non-inferiority of ticagrelor to clopidogrel followed by ticagrelor re-LD regarding platelet reactivity at 24 h using a prespecified margin of <35 PRU for the upper bound of the one-sided 97.5% confidence interval (CI). Ticagrelor was proven non-inferior to clopidogrel followed by ticagrelor re-LD with a difference between arms of 13.5 PRU (28.8 upper 97.5% CI), p = 0.001. At Hour 2, platelet reactivity was lower in ticagrelor only vs clopidogrel followed by ticagrelor re-LD groups with least square estimate mean difference (95% CI) -105.7 (-140.6 to -70.8), p < 0.001, without significant difference thereafter. In conclusion, in patients undergoing primary PCI, a strategy of ticagrelor LD only was proven non-inferior to clopidogrel LD followed by ticagrelor re-LD, in terms of antiplatelet efficacy at 24 h post-randomization and provided an earlier onset of platelet inhibition.

Ticagrelor versus high dose clopidogrel in ST-segment elevation myocardial infarction patients with high platelet reactivity post fibrinolysis.

Limited data are available on high platelet reactivity (HPR) rate early post fibrinolysis, while no effective way to overcome it has been proposed. In this context, we aimed to compare ticagrelor versus high dose clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) who exhibit HPR post fibrinolysis. In a prospective, randomized, parallel design, 3-center study, 56 STEMI patients, out of 83 (67.5 %) screened, who presented with HPR (PRU ≥ 208 by VerifyNow) 3-48 h post fibrinolysis and prior to coronary angiography were allocated to ticagrelor 180 mg loading dose (LD)/90 mg bid maintenance dose (MD) or clopidogrel 600 mg LD/150 mg MD. Platelet reactivity was assessed at randomization (Hour 0), at Hour 2, Hour 24 and pre-discharge. The primary endpoint of platelet reactivity (in PRU) at Hour 2 was significantly lower for ticagrelor compared to clopidogrel with a least square mean difference (95 % confidence interval) of -141.7 (-173.4 to -109.9), p < 0.001. HPR rates at Hour 2 and 24 were significantly lower for ticagrelor versus clopidogrel (14.3 vs. 82.1 %, p < 0.001 and 0 vs. 25.0 %, p = 0.01 respectively), though not significantly different pre-discharge. In-hospital Bleeding Academic Research Consortium type ≥2 bleeding occurred in 1 and 2 clopidogrel and ticagrelor-treated patients, respectively. In STEMI patients, post fibrinolysis HPR is common. Ticagrelor treats HPR more effectively compared to high dose clopidogrel therapy. Although antiplatelet regimens tested in this study were well tolerated, this finding should be considered only exploratory.

Absence of differential effect of ticagrelor versus prasugrel maintenance dose on endothelial function in patients with stable coronary artery disease.

BACKGROUND: Endothelial function may be improved by ticagrelor through adenosine-mediated mechanisms. We aimed to assess the effect of ticagrelor versus prasugrel on endothelial function in patients with stable coronary artery disease (CAD). METHODS: In a prospective, randomized, crossover study, 22 stable CAD patients under prasugrel 10 mg once daily maintenance dose (MD) for at least 3 months were randomized to either ticagrelor 90 mg twice daily or prasugrel 10 mg once daily for 15 days with a direct treatment-crossover for another 15 days. Endothelial function was assessed by peripheral arterial tonometry (EndoPAT 2000 system, Itamar Medical, Caesarea, Israel) at Day 0 (randomization), Day 15, and Day 30. Reactive Hyperemia Index (RHI) was calculated by using an automated software, and endothelial dysfunction (ED) was defined as RHI <1.67. RHI at the end of the two treatment periods did not differ between ticagrelor and prasugrel MD treatments. Least squares estimates (95% confidence interval) were 1.78 (1.58-1.99) versus 1.88 (1.67-2.08), with a fixed estimate of -0.099 (95% CI: -0.45 to 0.25) for the difference between them (p = 0.5). ED rate did not differ significantly between ticagrelor and prasugrel (45.5% vs 45.5%, p = 0.6). CONCLUSIONS: In CAD patients, we have failed to find evidence of alteration of endothelial function following ticagrelor compared to prasugrel MD treatment, as assessed by peripheral arterial tonometry. CLINICALTRIALS. GOV UNIQUE IDENTIFIER: NCT01957540.

Multi-center feasibility study of microwave radiometry thermometry for non-invasive differential diagnosis of arterial disease in diabetic patients with suspected critical limb ischemia.

AIMS: Diagnosis of vascular involvement in diabetic foot ulceration (DFU) remains challenging. We conducted a proof of concept study to investigate the feasibility of microwave radiometry (MWR) thermometry for non-invasive differential diagnosis of critical limb ischemia (CLI) in subjects with DFU. METHODS: This prospective, multi-center, study included 80 participants, divided into four groups (group N: normal control subjects; group DN: participants with diabetes and verified neuropathic ulcers without vascular involvement; group DC: participants with diabetes and CLI and group NDC: participants with CLI without diabetes). Vascular disease was confirmed with angiography. All patients underwent MWR (RTM-01-RES:University of Bolton, UK) to record mean tissue temperatures at various pre-determined foot sites. Comparisons of temperature measurements between study groups were performed using one-way ANOVA and Dunn tests. ROC analysis was performed to determine sensitivity, specificity and cut-off value of MWR for CLI diagnosis. RESULTS: Temperatures recorded in vicinity to the foot ulcers of participants with diabetes and CLI were similar to those with CLI without diabetes, but significantly lower than in subjects with neuropathic ulcers without vascular involvement and normal controls (group DC:29.30°C±1.89 vs. group NDC:29.18°C±1.78vs. group N:33.01°C±0.45 vs. group DN:33.39°C±1.37;P<.0001). According to ROC analysis, cut-off temperature value to diagnose CLI was <31.8°C (area under the curve: 0.984; 95% CI: 0.965-1.005;P<.001), with a sensitivity of 100.0% (95%CI: 90.26-100.0) and specificity of 88.37% (95% CI: 74.92-96.11). CONCLUSIONS: Tissue temperatures in vicinity to ulcers were significantly lower in participants with CLI, with or without diabetes, compared to non-ischemic controls. MWR could be used for differential diagnosis of arterial ischemia in subjects with DFU.

Noninvasive detection of increased carotid artery temperature in patients with coronary artery disease predicts major cardiovascular events at one year: Results from a prospective multicenter study.

BACKGROUND AND AIMS: Limited prospective data have been reported regarding the impact of carotid inflammation on cardiovascular events in patients with coronary artery disease (CAD). Microwave radiometry (MWR) is a noninvasive, simple method that has been used for evaluation of carotid artery temperature which, when increased, predicts 'inflamed' plaques with vulnerable characteristics. We prospectively tested the hypothesis that increased carotid artery temperature predicts future cerebro- and cardiovascular events in patients with CAD. METHODS: Consecutive patients from 3 centers, with documented CAD by coronary angiography, were studied. In both carotid arteries, common carotid intima-media thickness and plaque thickness were evaluated by ultrasound. Temperature difference (ΔT), measured by MWR, was considered as the maximal temperature along the carotid artery minus the minimum; ΔT ≥0.90 °C was assigned as high. Major cardiovascular events (MACE, death, stroke, myocardial infarction or revascularization) were recorded during the following year. RESULTS: In total, 250 patients were studied; of them 40 patients (16%) had high ΔT values in both carotid arteries. MACEs occurred in 30% of patients having bilateral high ΔT versus 3.8% in the remaining patients (p<0.001). Bilateral high ΔT was independently associated with increased one-year MACE rate (HR = 6.32, 95% CI 2.42-16.53, p<0.001, by multivariate cox regression hazard model). The addition of ΔT information on a baseline model based on cardiovascular risk factors and extent of CAD significantly increased the prognostic value of the model (c-statistic increase 0.744 to 0.845, pdif = 0.05) CONCLUSIONS: Carotid inflammation, detected by MWR, has an incremental prognostic value in patients with documented CAD.

Crushed Versus Integral Tablets of Ticagrelor in ST-Segment Elevation Myocardial Infarction Patients: A Randomized Pharmacokinetic/Pharmacodynamic Study.

OBJECTIVE: The objective of this study was to assess the pharmacokinetic and pharmacodynamic behavior of ticagrelor administered either as crushed (in the semi-upright sitting position) or as integral (in the supine position) tablets in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). METHODS: We randomized 20 patients to ticagrelor 180 mg either as 2 integral tablets administered in the supine position (standard administration) or as 2 tablets crushed and dispersed, administered in the semi-upright sitting position. Blood samples were drawn for pharmacokinetic and pharmacodynamic assessment at randomization (0 h) and at 0.5, 1, 2, and 4 h. RESULTS: At 1 h, ticagrelor plasma exposure and area under the plasma concentration-time curve from time zero to 1 h (AUC1) (co-primary endpoints) were higher in the crushed versus integral tablets group (median 586 vs. 70.1 ng/mL and 234 vs. 24.4 ng·h/mL, respectively), with a ratio of adjusted geometric means (95% confidence interval [CI]) of 12.67 (2.34-68.51) [p = 0.005] and 19.28 (3.51-106.06) [p = 0.002], respectively. Time to maximum plasma concentration was shorter in the crushed versus integral tablets group (median 2 vs. 4 h), with a ratio of adjusted geometric means (95% CI) of 0.69 (0.49-0.97) [p = 0.035]. Parallel findings were observed with AR-C124910XX (active metabolite). Platelet reactivity (VerifyNow(®)) at 1 h was lower with crushed versus standard administration with least squares estimates mean difference (95% CI) of 92 (-158.4 to 26.6) P2Y12 reaction units (p = 0.009). CONCLUSIONS: In patients with STEMI undergoing primary PCI, ticagrelor crushed tablets administered in the semi-upright sitting position seems to lead to a faster-compared with standard administration-absorption, with stronger antiplatelet activity within the first hour. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02046486.