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1.
Int Heart J ; 62(1): 171-174, 2021 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-33455983

RESUMO

A 41-year-old woman with chest pain for 6 hours was admitted to our chest pain center, presenting with acute myocardial infarction. Coronary angiography showed acute total occlusion in the proximal left anterior descending artery due to late stent thrombosis. After thrombus aspiration and intracoronary administration of 0.5 mg tirofiban, repeated angiography showed that no obvious residual stenosis remained. The patient underwent drug-coated balloon angioplasty 69 days ago and was then administered dual antiplatelet treatment (aspirin and clopidogrel) uninterruptedly. Genetic testing found that both cytochrome P450 2C19 (CYP2C19) (G681A) and glycoprotein Ia (GPIa) (C807T, G873A) were hybrid mutant types, demonstrating that the patient was possibly resistant to clopidogrel and aspirin simultaneously. Thus, clopidogrel was replaced by ticagrelor and no more cardiovascular adverse events occurred during the 2-year follow-up.


Assuntos
Oclusão Coronária/etiologia , Reestenose Coronária/etiologia , Infarto do Miocárdio/diagnóstico , Doença Aguda , Adulto , Assistência ao Convalescente , Angioplastia Coronária com Balão/métodos , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Clopidogrel/uso terapêutico , Angiografia Coronária/métodos , Oclusão Coronária/diagnóstico por imagem , Reestenose Coronária/terapia , Citocromo P-450 CYP2C19/genética , Terapia Antiplaquetária Dupla/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Feminino , Fibrinolíticos/administração & dosagem , Fibrinolíticos/uso terapêutico , Humanos , Integrina alfa2/genética , Mutação/genética , Infarto do Miocárdio/etiologia , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Stents/efeitos adversos , Trombectomia/métodos , Trombose/terapia , Ticagrelor/administração & dosagem , Ticagrelor/uso terapêutico , Tirofibana/administração & dosagem , Tirofibana/uso terapêutico , Resultado do Tratamento
2.
Lancet ; 396(10257): 1079-1089, 2020 10 10.
Artigo em Inglês | MEDLINE | ID: mdl-32882163

RESUMO

BACKGROUND: A potent P2Y12 inhibitor-based dual antiplatelet therapy is recommended for up to 1 year in patients with acute coronary syndrome receiving percutaneous coronary intervention (PCI). The greatest benefit of the potent agent is during the early phase, whereas the risk of excess bleeding continues in the chronic maintenance phase. Therefore, de-escalation of antiplatelet therapy might achieve an optimal balance between ischaemia and bleeding. We aimed to investigate the safety and efficacy of a prasugrel-based dose de-escalation therapy. METHODS: HOST-REDUCE-POLYTECH-ACS is a randomised, open-label, multicentre, non-inferiority trial done at 35 hospitals in South Korea. We enrolled patients with acute coronary syndrome receiving PCI. Patients meeting the core indication for prasugrel were randomly assigned (1:1) to the de-escalation group or conventional group using a web-based randomisation system. The assessors were masked to the treatment allocation. After 1 month of treatment with 10 mg prasugrel plus 100 mg aspirin daily, the de-escalation group received 5 mg prasugrel, while the conventional group continued to receive 10 mg. The primary endpoint was net adverse clinical events (all-cause death, non-fatal myocardial infarction, stent thrombosis, repeat revascularisation, stroke, and bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria) at 1 year. The absolute non-inferiority margin for the primary endpoint was 2·5%. The key secondary endpoints were efficacy outcomes (cardiovascular death, myocardial infarction, stent thrombosis, and ischaemic stroke) and safety outcomes (bleeding events of BARC grade ≥2). The primary analysis was in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02193971. RESULTS: From Sept 30, 2014, to Dec 18, 2018, 3429 patients were screened, of whom 1075 patients did not meet the core indication for prasugrel and 16 were excluded due to randomisation error. 2338 patients were randomly assigned to the de-escalation group (n=1170) or the conventional group (n=1168). The primary endpoint occurred in 82 patients (Kaplan-Meier estimate 7·2%) in the de-escalation group and 116 patients (10·1%) in the conventional group (absolute risk difference -2·9%, pnon-inferiority<0·0001; hazard ratio 0·70 [95% CI 0·52-0·92], pequivalence=0·012). There was no increase in ischaemic risk in the de-escalation group compared with the conventional group (0·76 [0·40-1·45]; p=0·40), and the risk of bleeding events was significantly decreased (0·48 [0·32-0·73]; p=0·0007). INTERPRETATION: In east Asian patients with acute coronary syndrome patients receiving PCI, a prasugrel-based dose de-escalation strategy from 1 month after PCI reduced the risk of net clinical outcomes up to 1 year, mainly driven by a reduction in bleeding without an increase in ischaemia. FUNDING: Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Terapia Antiplaquetária Dupla/métodos , Hemorragia/induzido quimicamente , Inibidores da Agregação de Plaquetas/administração & dosagem , Cloridrato de Prasugrel/administração & dosagem , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/cirurgia , Idoso , Aspirina/administração & dosagem , Relação Dose-Resposta a Droga , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos
3.
Am Heart J ; 228: 1-7, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32739652

RESUMO

BACKGROUND: Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is the cornerstone for prevention ischemic events in patients with acute coronary syndromes (ACS) and undergoing percutaneous coronary intervention. However, the optimal antiplatelet strategy for ACS patients with both high bleeding and high ischemic risks is unclear. STUDY DESIGN: The OPT-BIRISK trial is a multicenter, double-blinded, placebo-controlled randomized study designed to test the superiority of extended antiplatelet therapy with clopidogrel monotherapy compared with aspirin and clopidogrel for reduction of bleeding events in ACS patients with both high bleeding and high ischemic risks ("bi-risk"). A total of 7,700 patients who completed 9- to 12-month dual antiplatelet therapy after new-generation drug-eluting stent implantation for the treatment of ACS will be randomized to receive clopidogrel monotherapy or aspirin plus clopidogrel for 9 months followed by aspirin monotherapy for 3 months. The primary end point is Bleeding Academic Research Consortium type 2, 3, or 5 bleedings at 9 months after randomization. The key secondary end point is major adverse cardiac and cerebral events at 9 months after randomization, defined as a composite of all-cause death, myocardial infarction, stroke, or coronary artery revascularization. CONCLUSIONS: OPT-BIRISK is the first large-scale randomized trial aimed to explore the optimal antiplatelet strategy for bi-risk ACS patients after percutaneous coronary intervention in current clinical practice. The results will add evidence regarding de-escalation antiplatelet therapy for patients at special risk.


Assuntos
Síndrome Coronariana Aguda , Aspirina , Clopidogrel , Hemorragia , Risco Ajustado/métodos , Acidente Vascular Cerebral , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Adulto , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Método Duplo-Cego , Stents Farmacológicos/efeitos adversos , Terapia Antiplaquetária Dupla/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/induzido quimicamente , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
4.
Am Heart J ; 228: 8-16, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32745734

RESUMO

BACKGROUND: Gastrointestinal injury is a common complication in patients treated with antiplatelet agents after percutaneous coronary intervention (PCI). However, the effects of different antiplatelet regimens on the incidence and severity of gastrointestinal injury have not been well studied, principally due to the lack of a low-risk sensitive and accurate detection system. TRIAL DESIGN: OPT-PEACE is a multicenter, randomized, double-blind, placebo-controlled trial. Gastrointestinal injury will be evaluated with the ANKON magnetically controlled capsule endoscopy system (AMCE), a minimally invasive approach for detecting mucosal lesions in the stomach, duodenum and small intestine. Patients without AMCE-detected gastrointestinal erosions, ulceration or bleeding after drug-eluting stent implantation are enrolled and treated with open-label aspirin (100 mg/d) plus clopidogrel (75 mg/d) for 6 months. Thereafter, 480 event-free patients will undergo repeat AMCE and are randomly assigned in a 1:1:1 ratio to receive aspirin plus clopidogrel, aspirin plus placebo or clopidogrel plus placebo for an additional 6 months. A final AMCE is performed at 12 months. The primary endpoint is the incidence of gastric or intestinal mucosal lesions (erosions, ulceration, or bleeding) within 12 months after enrollment. CONCLUSIONS: OPT-PEACE is the first study to investigate the incidence and severity of gastrointestinal injury in patients receiving different antiplatelet therapy regimens after stent implantation. This trial will inform clinical decision-making for personalized antiplatelet therapy post-PCI.


Assuntos
Aspirina , Endoscopia por Cápsula/métodos , Clopidogrel , Doença da Artéria Coronariana , Hemorragia Gastrointestinal , Intervenção Coronária Percutânea , Adulto , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/cirurgia , Método Duplo-Cego , Stents Farmacológicos , Terapia Antiplaquetária Dupla/métodos , Feminino , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/prevenção & controle , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco Ajustado/métodos
5.
Am J Cardiol ; 132: 44-51, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32762964

RESUMO

The optimal duration of dual antiplatelet therapy (DAPT) after treatment of chronic total occlusions (CTO) with percutaneous coronary intervention (PCI) is unknown. We aimed to determine if extended (> 12 months) DAPT was associated with a net clinical benefit. The study population included patients who underwent successful CTO PCI within Kaiser Permanente Northern California between 2009 and 2016. Baseline demographic, clinical, and procedural characteristics were compared for patients on DAPT ≤ versus > 12 months. Clinical outcomes (death, myocardial infarction (MI), and ≥ Academic Research Consortium type 3a bleeding) were compared beginning 12 months after PCI using Cox proportional hazards models. We also adjudicated individual causes of death. 1,069 patients were followed for a median of 3.6 years (Interquartile Range = 2.2 to 5.5) following CTO PCI. Patients on DAPT ≤ 12 months (n = 597, 56%) were more likely to have anemia, end stage renal disease, and previous MI. After adjustment for between group differences, > 12 months of DAPT was associated with lower death or MI (hazard ratio [HR]: 0.66; 95% confidence interval [CI]: 0.47 to 0.93) and lower death (HR: 0.54; 95% CI: 0.36 to 0.82). There were no associations with MI (HR: 0.91; 95% CI: 0.55 to 1.5) or bleeding (HR 1.1; 95% CI: 0.50 to 2.4), but a numerically higher proportion of patients on shorter v. longer DAPT died of a cardiovascular cause (37% vs 20%, p = 0.10). In conclusion, > 12 months of DAPT was associated with lower death or MI, without an increase in bleeding. Prospective studies are needed to evaluate the optimal duration of DAPT in this unique subgroup.


Assuntos
Oclusão Coronária/terapia , Terapia Antiplaquetária Dupla/métodos , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , California/epidemiologia , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico , Oclusão Coronária/mortalidade , Esquema de Medicação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo
6.
Am Heart J ; 227: 82-90, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32693196

RESUMO

BACKGROUND: A number of trials have assessed the efficacy and safety of short-term dual antiplatelet therapy (DAPT) in patients who undergo percutaneous coronary intervention (PCI). However, whether to continue aspirin or a P2Y12 inhibitor after a short course of DAPT is actively debated. METHODS: PUBMED and EMBASE were searched through March 2020 for randomized controlled trials evaluating short-term DAPT (≤6 months) when compared with longer-term (≥12 months) DAPT among patients undergoing PCI. The ischemic outcomes were all-cause death, myocardial infarction, stent thrombosis, and stroke. The safety outcome was major and/or clinically relevant bleeding. The primary objective was to investigate the outcomes with aspirin monotherapy (Aspirin group) versus P2Y12 inhibitor monotherapy (P2Y12i group) after short-term DAPT. RESULTS: Our search identified 17 eligible trials enrolling a total of 54,625 patients comparing different DAPT duration. Either of the 2 monotherapy groups did not increase the risk of ischemic outcomes when compared with the long-term DAPT group, without difference between the Aspirin versus the P2Y12i groups. However, both monotherapy groups significantly reduced bleeding when compared with long-term DAPT (Aspirin group: hazard ratio [95% CI]: 0.62 [0.45-0.86], P=.004 and P2Y12i group: 0.68 [0.50-0.93], P=.015). There was no difference in bleeding between the Aspirin versus P2Y12i groups (hazard ratio=0.91 [0.58-1.43], P=.70). CONCLUSIONS: Among patients undergoing PCI, short-term DAPT with continuation of either aspirin or P2Y12i reduced bleeding without increasing ischemic outcomes when compared with long-term DAPT. The choice of antiplatelet therapy after short-term DAPT should be evaluated in well-powered trials.


Assuntos
Aspirina/administração & dosagem , Terapia Antiplaquetária Dupla/métodos , Metanálise em Rede , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
7.
Yonsei Med J ; 61(7): 597-605, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32608203

RESUMO

PURPOSE: Although current guidelines recommend the administration of dual antiplatelet therapy (DAPT) for up to 12 months after the implantation of a drug-eluting stent (DES), extended DAPT is frequently used in real-world practice. MATERIALS AND METHODS: From the Korean Multicenter Angioplasty Team registry, we identified a total of 1414 patients who used DAPT for >3 years after DES implantation (extended-DAPT group) and conducted a landmark analysis at 36 months after the index procedure. We evaluated the determinants for and long-term outcomes of extended DAPT and compared the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke, between the extended-DAPT group and the guideline-DAPT group [DAPT <1 year after DES implantation (n=1273)]. RESULTS: Multivariate analysis indicated the occurrence of acute coronary syndrome as the most significant clinical determinant of the use of extended DAPT. Bifurcation, stent diameter ≤3.0 mm, total stented length ≥28 mm, and use of first-generation DESs were also significant angiographic and procedural determinants. MACCE rates were similar between the extended-DAPT group and the guideline-DAPT group in crude analysis [hazard ratio (HR), 1.08; 95% confidence interval (CI), 0.69-1.68; p=0.739] and after propensity matching (HR, 1.22; 95% CI, 0.72-2.07; p=0.453). Major bleeding rates were comparable between the two groups. CONCLUSION: In patients undergoing percutaneous coronary intervention, indefinite use of DAPT does not show superior outcomes to those of guideline-DAPT. Major bleeding rates are also similar.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Doença da Artéria Coronariana/tratamento farmacológico , Stents Farmacológicos/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/uso terapêutico , Idoso , Doenças Cardiovasculares/epidemiologia , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/terapia , Trombose Coronária/prevenção & controle , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/etiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Trombose/complicações , Fatores de Tempo , Resultado do Tratamento
9.
Am J Cardiol ; 127: 25-29, 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32389351

RESUMO

The optimal duration of dual antiplatelet therapy (DAPT) in the era of second-generation drug-eluting stents is a matter of considerable debate with more data suggesting a shorter period of DAPT is feasible. We performed a meta-analysis to evaluate DAPT compared with monotherapy with a P2Y12 inhibitor after a percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane Central were searched from inception to October 2019 to identify randomized controlled trials that compared outcomes of patients treated with either DAPT or monotherapy with a P2Y12 inhibitor following PCI. Primary outcomes of interest included major bleeding, ischemic events (myocardial infarction, stroke, stent thrombosis, major adverse cardiac events), and both all-cause and cardiovascular mortality. Event rates were extracted, and the Mantel-Haenszel fixed-effects model was used to perform a meta-analysis. Summary statistics are reported as odds ratios with 95% confidence intervals. Subgroup analyses were performed using the generic inverse method. We identified four trials with 29,089 randomized patients. Use of P2Y12 monotherapy was associated with 30% lower odds of major bleeding 0.70 (0.60-0.81; p <0.01). Ischemic and mortality outcomes were similar in the two groups. For the outcome of major bleeding the results favor the use of P2Y12 monotherapy in the subgroups of age, sex, diabetes, chronic kidney disease, acute coronary syndrome, and multivessel disease. The present meta-analysis provides the most updated data on the use of DAPT duration. Following an initial period of short-term DAPT, monotherapy with a P2Y12 inhibitor appears to be the superior strategy for optimization of bleeding and thrombotic risk after PCI.


Assuntos
Doença da Artéria Coronariana/terapia , Terapia Antiplaquetária Dupla/métodos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Humanos , Resultado do Tratamento
10.
Int J Clin Pract ; 74(7): e13504, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32243645

RESUMO

PURPOSE: The purpose of this study is to assess the effectiveness of mono antiplatelet therapy vs dual antiplatelet therapy in reducing recurrent stroke and mortality in patients with ischemic stroke or transient ischemic attack (TIA). A subgroup analysis was conducted to compare outcomes in African-American patients compared with non-African-American patients. METHODS: This is a single-centre, retrospective, chart review, cohort study conducted at the University Medical Center New Orleans (UMCNO), New Orleans, Louisiana. This study includes all patients who are admitted to UMCNO with a diagnosis of ischemic stroke or TIA. The subjects were divided into two groups, patients who received mono antiplatelet therapy and patients who received dual antiplatelet therapy. RESULTS: A total of 762 stroke patients were included in the study. Of these, 499 (65.5%) received mono antiplatelet therapy and 263 (34.5%) patients received dual antiplatelet therapy. There was no statistical significant difference in the incidence of mortality and recurrent stroke in the mono antiplatelet therapy group compared with the dual antiplatelet therapy group. When comparing primary outcomes between African Americans and non-African Americans, there was no statistical significant difference in mortality rate and recurrent stroke rate between the two groups. CONCLUSION: This study found no statistical significant difference in the incidence of recurrent stroke and mortality between mono antiplatelet therapy and dual antiplatelet therapy among patients who had ischemic stroke or TIA; with similar findings in a subgroup analysis comparing outcomes in African-American patients compared with non-African-American patients.


Assuntos
Afro-Americanos/estatística & dados numéricos , Isquemia Encefálica/tratamento farmacológico , Terapia Antiplaquetária Dupla/métodos , Ataque Isquêmico Transitório/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária/métodos , Estudos de Coortes , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/terapia
11.
Am J Cardiol ; 125(11): 1631-1637, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32273057

RESUMO

Patients undergoing percutaneous coronary intervention (PCI) often have high-bleeding-risk (HBR) factors. Dual antiplatelet therapy (DAPT) further increases this risk of bleeding. We sought to compare clinical outcomes according to presence or absence of HBR factors in patients with elevated ischemic risk (DAPT score ≥ 2) undergoing PCI. We evaluated all patients undergoing PCI at MedStar Washington Hospital Center (January 2009 to July 2018) with DAPT score ≥2, which is associated with elevated risk of ischemic events. Patients were categorized as HBR group (HBR score ≥1) or low-bleeding-risk (LBR) group (HBR score = 0). Outcomes included major adverse cardiac events such as target vessel revascularization, stent thrombosis, death, and bleeding events at 30 days, 6 months, 1 year, and 2 years. The final cohort consisted of 7,499 patients: 3,949 patients had LBR features, and 3,550 patients had HBR features. The 2 groups were different at baseline, with HBR patients being older and having a higher prevalence of congestive heart failure and renal dysfunction than the LBR group. The mean DAPT score was 2.96±1.1 for the LBR group and 3.7±1.4 for the HBR group (p <0.001). During follow-up at 30 days, 6 months, and 1 and 2 years, the rates of target vessel revascularization and stent thrombosis were not significantly different between the 2 groups. Bleeding events and all-cause mortality were significantly more frequent in the HBR group than in the LBR group. In conclusion, patients undergoing PCI often have pre-existing risk factors that predispose them to ischemic and bleeding complications. Prolonged duration of DAPT to mitigate ischemic events could lead to a disproportionate increase in bleeding events, especially in HBR patients.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Doença da Artéria Coronariana/terapia , Hemorragia/epidemiologia , Revascularização Miocárdica/estatística & dados numéricos , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/epidemiologia , Idoso , Causas de Morte , Comorbidade , Terapia Antiplaquetária Dupla/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Feminino , Hemorragia Gastrointestinal/epidemiologia , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Prevalência , Insuficiência Renal/epidemiologia , Risco , Medição de Risco , Stents
12.
G Ital Cardiol (Rome) ; 21(2 Suppl 1): 14S-25S, 2020 02.
Artigo em Italiano | MEDLINE | ID: mdl-32134404

RESUMO

Dual antiplatelet therapy (DAPT) is a cornerstone of antithrombotic treatment in patients undergoing percutaneous coronary intervention. The optimal duration of DAPT, i.e. the minimal period needed to ensure the best safety and efficacy, to prevent ischemic complications, including stent thrombosis, has been extensively explored in multiple randomized controlled trials over the last years. Accumulating evidence is supporting a clinical approach where there is a prevailing role of the risk of bleeding: in patients at high bleeding risk (HBR) it is generally advisable to reduce the duration of DAPT irrespective of their risk of thrombosis. In addition, among HBR patients, (i) new recommendations prefer direct oral anticoagulants (DOAC) over vitamin K antagonists in DOAC-eligible patients with atrial fibrillation and coronary artery disease; (ii) measures to minimize bleedings while on DAPT should be pursued, including de-escalation of P2Y12 receptor inhibitor therapy; and (iii) new studies are testing reversal strategies for short DAPT regimens, with early discontinuation of aspirin. In the present review, we discuss the rationale and decision-making considerations to reduce safely DAPT duration in HBR patients.


Assuntos
Terapia Antiplaquetária Dupla/métodos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Anticoagulantes/administração & dosagem , Aspirina/administração & dosagem , Fibrilação Atrial/terapia , Doença da Artéria Coronariana/terapia , Terapia Antiplaquetária Dupla/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/etiologia , Trombose/prevenção & controle , Fatores de Tempo
13.
G Ital Cardiol (Rome) ; 21(2 Suppl 1): 26S-33S, 2020 02.
Artigo em Italiano | MEDLINE | ID: mdl-32134405

RESUMO

In patients with atrial fibrillation (AF) who undergo an acute coronary syndrome (ACS), with or without percutaneous coronary intervention and coronary stent implantation, the association of dual antiplatelet therapy with an oral anticoagulant (also known as triple antithrombotic therapy, TAT) increases the risk for major and fatal bleeding. Recently, several trials have evaluated alternative therapeutic regimens to TAT, such as dual antithrombotic therapy (DAT) comprising a direct oral anticoagulant and a platelet P2Y12 receptor inhibitor. In the context of patients treated with percutaneous coronary intervention, these regimens have generally been associated with a reduction in bleeding that was not accompanied by a substantial increase in ischemic events. However, the net benefit of DAT is more controversial in the case of patients at higher thrombotic risk, such as patients with ACS. This review, based on the available literature, describes the best peri-procedural and post-procedural antithrombotic strategies for patients with AF and ACS.


Assuntos
Síndrome Coronariana Aguda/terapia , Fibrilação Atrial/terapia , Terapia Antiplaquetária Dupla/métodos , Administração Oral , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Terapia Antiplaquetária Dupla/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Stents , Trombose/etiologia , Trombose/prevenção & controle
14.
G Ital Cardiol (Rome) ; 21(2 Suppl 1): 34S-41S, 2020 02.
Artigo em Italiano | MEDLINE | ID: mdl-32134406

RESUMO

Bleeding is a frequently encountered complication in patients undergoing percutaneous coronary intervention (PCI) treated with a dual antiplatelet therapy regimen with aspirin plus an oral inhibitor of the P2Y12 platelet receptor (clopidogrel, prasugrel, ticagrelor) or with the combination of antiplatelet drugs and an anticoagulant in patients who have a specific indication for chronic anticoagulation therapy such as atrial fibrillation. The management of antithrombotic therapy during post-PCI bleeding is considerably challenging due to the intrinsic difficulty in estimating the balance between the bleeding risk - increased by antiplatelet and/or anticoagulant therapy - and the thrombotic risk associated with the possible discontinuation of these drugs. Currently, there are no data derived from dedicated studies in this setting and therefore the management of antithrombotic therapy in patients who suffer a hemorrhagic complication after PCI is guided by consensus documents that provide suggestions for the different types of bleeding, based on the severity of the latter. In light of the European documents available, this article will discuss the possible management strategies of antithrombotic therapy (antiplatelet and/or anticoagulant) in the different types of bleeding that can occur in patients undergoing PCI.


Assuntos
Anticoagulantes/administração & dosagem , Hemorragia/prevenção & controle , Inibidores da Agregação de Plaquetas/administração & dosagem , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Terapia Antiplaquetária Dupla/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Hemorragia/induzido quimicamente , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/efeitos adversos , Trombose/etiologia , Trombose/prevenção & controle
15.
G Ital Cardiol (Rome) ; 21(2 Suppl 1): 42S-47S, 2020 02.
Artigo em Italiano | MEDLINE | ID: mdl-32134407

RESUMO

Although having different rationales and purposes, the PEGASUS-TIMI 54 and COMPASS trials present various points of contact and, especially after the first recommended year of dual antiplatelet therapy (DAPT) from an acute coronary syndrome, pose the clinical question of whether DAPT should be prolonged (PEGASUS strategy) or aspirin should be maintained by combining rivaroxaban 2.5 mg bid (COMPASS strategy). In this review, we try to trace the PEGASUS and COMPASS patient's profile by analyzing the design of each study with their inclusion/exclusion criteria, the main subanalyses and the real-world studies recently published in this setting.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Terapia Antiplaquetária Dupla/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Aspirina/administração & dosagem , Humanos , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Rivaroxabana/administração & dosagem , Fatores de Tempo
16.
Am J Cardiol ; 125(8): 1280-1283, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32081368

RESUMO

Intraocular bleeding is a devastating clinical event due to its potentially blinding nature. It is not known if determine if dual antiplatelet therapy using aspirin and potent P2Y12 inhibitors increases this risk. We searched MEDLINE and ClinicalTrials.gov for randomized controlled trials that were phase III, randomly assigned patients to dual antiplatelet therapy with either aspirin and a potent P2Y12 inhibitor or aspirin and clopidogrel, had follow-up of 6 months, and at least 200 patients. Corresponding authors were contacted for intraocular bleeding data. Inverse-variance, weighted, fixed-effects meta-analysis was undertaken, with random-effects meta-analysis performed as a sensitivity analysis. Four trials enrolling 42,850 patients were included. The median follow-up ranged from 12 to 14 months. There was overall low risk of bias. Pooled analysis demonstrated no statistically significant increase in the risk of intraocular bleeding with dual antiplatelet therapy using potent P2Y12 inhibitors compared with clopidogrel (risk ratio 0.89, 95% confidence interval 0.58 to 1.36). There was no significant heterogeneity observed across trials (I2 statistic 0%, p = 0.98). The use of random-effects meta-analysis did not change the effect estimate or confidence intervals, and the results appeared similar when stratified by potent P2Y12 inhibitor (p = 0.97). In conclusion, this collaborative meta-analysis of dual antiplatelet trials does not suggest that the risk of intraocular bleeding is increased with the use of potent P2Y12 inhibitors compared with clopidogrel. Our results suggest that these potent P2Y12 inhibitors may continue to be used cautiously where indicated as part of dual antiplatelet therapy, even in those at high risk of spontaneous intraocular bleeding.


Assuntos
Aspirina/uso terapêutico , Hemorragia Ocular/epidemiologia , Inibidores da Agregação de Plaquetas/uso terapêutico , Cloridrato de Prasugrel/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Ticagrelor/uso terapêutico , Ensaios Clínicos Fase III como Assunto , Clopidogrel/uso terapêutico , Terapia Antiplaquetária Dupla/métodos , Hemorragia Ocular/induzido quimicamente , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
Postgrad Med J ; 96(1131): 9-13, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31324730

RESUMO

BACKGROUND: After primary percutaneous coronary intervention (PPCI) in patients with acute ST elevation myocardial infarction (STEMI), dual antiplatelet therapy (DAPT) is recommended to continue for 1 year. Occasionally, DAPT interruption may be required due to bleeding issues or unplanned surgical procedures. OBJECTIVE: To systematically evaluate the incidence of DAPT interruption within 1 year after PPCI. METHODS AND RESULTS: This was a single-centre, retrospective registry study. Consecutive patients with STEMI who underwent PPCI from 2013 to 2017 (N=538) were recruited into the analysis. The primary outcome was the incidence of interruption of DAPT within 1 year from the index PPCI. Secondary outcomes included incidence of bleeding in 1 year and prevalence of high bleeding risk (HBR) criteria at index presentation. Within 1 year, 17.1% (84/490) of post-PPCI survivors needed DAPT interruption and 7.1% (35/490) had major bleeding (Bleeding Academic Research Consortium type 3 or 5). At index presentation, HBR criteria were present in 36.1% (194/538) of patients. On univariate analysis, age, female gender, anaemia, anticoagulation, diabetes, hypertension and being a non-smoker were associated with DAPT interruption. On multivariate analysis, age was the only independent factor to predict DAPT interruption. CONCLUSION: DAPT interruption was not uncommon after PPCI in patients with STEMI particularly in the elderly. This has implication on stent selection during PPCI, and further studies are required to investigate which type of stent may best suit our real-life patients with STEMI.


Assuntos
Terapia Antiplaquetária Dupla , Hemorragia , Intervenção Coronária Percutânea , Complicações Pós-Operatórias , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Terapia Antiplaquetária Dupla/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Hemorragia/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Stents/normas , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Suspensão de Tratamento/estatística & dados numéricos
18.
Thromb Haemost ; 120(1): 83-93, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31470444

RESUMO

In patients requiring dual antiplatelet therapy (DAPT) who also have an indication to be treated with oral anticoagulant (OAC) drugs, aspirin withdrawal reduces the risk of bleeding. There is limited data on the pharmacodynamic effects associated with adding a nonvitamin K antagonist OAC on a background of aspirin and a P2Y12 inhibitor as well as dropping aspirin. Seventy-five patients on DAPT (aspirin plus clopidogrel) were randomized to DAPT plus high-dose edoxaban (60 mg once daily, Group A), DAPT plus low-dose edoxaban (30 mg once daily, Group B), or DAPT only (Group C) for 10 ± 2 days (Phase I). Afterwards, Groups A and B interrupted aspirin and maintained clopidogrel plus edoxaban for 10 ± 2 days, while patients in Group C maintained DAPT (Phase II). Platelet aggregation and clot kinetics were assessed at baseline, end of Phase I, and end of Phase II using thrombelastography (TEG), light transmittance aggregometry (LTA), VerifyNow P2Y12, and serum thromboxane-B2. The primary endpoint was the comparison of maximum amplitude (MA) measured by TEG, a measure of clot strength, between patients on DAPT plus high-dose edoxaban and patients on DAPT only. Edoxaban prolonged in a dose-dependent manner speed of thrombin generation (TEG R; Group A: 7.7 [6.8-8.7] vs. Group B: 7.4 [6.4-8.5] vs. Group C: 6.3 [5.7-7.0]; p = 0.05) but did not affect other markers of clot kinetics, including TEG MA (Group A: 63 [61-64] vs. Group B: 65 [63-67] vs. Group C: 64 [63-65]; p = 0.10). After aspirin discontinuation, platelet reactivity assessed by LTA using thrombin receptor activating peptide as agonist increased to a greater extent with low-dose edoxaban. Stopping aspirin did not affect markers of P2Y12 reactivity and had no or marginal effects on clot kinetics, but increased markers sensitive to cyclooxygenase-1 blockade.


Assuntos
Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Terapia Antiplaquetária Dupla/métodos , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Idoso , Coagulação Sanguínea , Doença da Artéria Coronariana/mortalidade , Ciclo-Oxigenase 1/metabolismo , Interações Medicamentosas , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Receptores Purinérgicos P2Y12/metabolismo , Análise de Sobrevida
19.
Int J Cardiol ; 300: 99-105, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31474410

RESUMO

OBJECTIVES: To assess the external validity of the Dual Antiplatelet Therapy (DAPT) score decision tool in real world patients. METHODS AND RESULTS: Retrospective study using an all comers PCI registry. We compared the rates of myocardial infarction (MI) and actionable bleeding between 12 vs. 12+ months DAPT stratified by DAPT score category. Of 12,162 patients, 4471 (36.8%) completed a year of DAPT without events. The high DAPT score stratum patients were older and had a higher comorbidity burden. Overall, 12+ months DAPT duration was associated with reduced rates of MI (2.8% vs. 4.0%, p = 0.025) and similar rates of bleeding (2.6% vs. 1.9%, p = 0.281) compared to 12 months DAPT, but when stratified by DAPT score stratum, there was no difference in any of the outcomes in both high score group, (3.7% vs. 5.3%, p = 0.111 and 2.0% vs. 1.8%, p = 0.800, for MI and bleeding, respectively) and low score patients (2.7% vs. 3.1%, p = 0.656 and 2.8% vs. 2.0%, p = 0.308, for MI and bleeding, respectively). Overall clinical events (MI + bleeding) was again similar between patients treated with 12+ vs. 12 months DAPT (5.5% vs. 6.2%, p = 0.535 and 5.1% vs. 4.4%, p = 0.503 for high and low DAPT score, respectively). CONCLUSIONS: for real world patients completing 1 year of DAPT post PCI, rates of MI, actionable bleeding, and their combination did not differ between those treated with 12+ vs. 12 months DAPT stratified by DAPT score stratum. Clinicians should be aware of the DAPT score's limitations. Further studies examining the validity of the DAPT score in larger cohorts are required.


Assuntos
Aspirina/administração & dosagem , Doença da Artéria Coronariana/diagnóstico , Stents Farmacológicos , Terapia Antiplaquetária Dupla/métodos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/cirurgia , Terapia Antiplaquetária Dupla/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos
20.
J Intensive Care Med ; 35(1): 68-73, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28931362

RESUMO

BACKGROUND: Thrombelastography (TEG) provides a global, dynamic measure of coagulation. We examined the effect of antiplatelet (AP) medications on coagulation in patients with acute stroke as measured by TEG. METHODS: We reviewed prospectively collected data on patients presenting with acute ischemic stroke (AIS) and spontaneous intracerebral hemorrhage (ICH) between 2009 and 2014. Patient demographics and baseline TEG values were compared among 4 different drug use groups: aspirin only, clopidogrel only, both aspirin and clopidogrel, and no AP. Multivariable regression models were conducted to compare the differences in TEG components. RESULTS: A total of 202 patients were included, 139 with AIS and 63 with ICH. Forty-eight (24%) patients were taking aspirin alone, 12 (6%) were taking clopidogrel, 16 (8%) dual AP, and 126 (62%) no AP. Dual AP use was associated with prolonged mean R (time to initiate clotting) of 5.5 minutes as compared to no AP use (4.6 minutes, P = .04). Additionally, mean maximal amplitude (MA; final clot strength) and angle (rate of clot formation) were decreased in the dual AP group (MA = 59.3 mm, angle = 57.8°) as compared to the no AP group (MA = 64.5 mm, angle = 64.5°; P = .04 and P = .01, respectively). Patients on single AP therapy (either aspirin or clopidogrel) did not differ from those on no AP therapy in any TEG parameters measured. CONCLUSION: Dual AP therapy is associated with a detectable coagulopathy which may have implications in the management of patients with AIS and hemorrhagic stroke. The effects of single AP therapy may not be demonstrated by TEG.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Terapia Antiplaquetária Dupla/métodos , Hemorragia/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Coagulação Sanguínea/fisiologia , Feminino , Hemorragia/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tromboelastografia
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