Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 159
Filtrar
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.
J Stroke Cerebrovasc Dis ; 30(2): 105520, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33310594

RESUMO

BACKGROUND: Ticagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. METHODS: We identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. RESULTS: Of the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. CONCLUSION: Despite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Terapia Trombolítica , Ticagrelor/administração & dosagem , Ativador de Plasminogênio Tecidual/administração & dosagem , Síndrome Coronariana Aguda/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Hemorragias Intracranianas/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Ticagrelor/efeitos adversos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
3.
JAMA ; 324(16): 1640-1650, 2020 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-33107944

RESUMO

Importance: Current guidelines recommend ticagrelor as the preferred P2Y12 platelet inhibitor for patients with acute coronary syndrome (ACS), primarily based on a single large randomized clinical trial. The benefits and risks associated with ticagrelor vs clopidogrel in routine practice merits attention. Objective: To determine the association of ticagrelor vs clopidogrel with ischemic and hemorrhagic events in patients undergoing percutaneous coronary intervention (PCI) for ACS in clinical practice. Design, Setting, and Participants: A retrospective cohort study of patients with ACS who underwent PCI and received ticagrelor or clopidogrel was conducted using 2 United States electronic health record-based databases and 1 nationwide South Korean database from November 2011 to March 2019. Patients were matched using a large-scale propensity score algorithm, and the date of final follow-up was March 2019. Exposures: Ticagrelor vs clopidogrel. Main Outcomes and Measures: The primary end point was net adverse clinical events (NACE) at 12 months, composed of ischemic events (recurrent myocardial infarction, revascularization, or ischemic stroke) and hemorrhagic events (hemorrhagic stroke or gastrointestinal bleeding). Secondary outcomes included NACE or mortality, all-cause mortality, ischemic events, hemorrhagic events, individual components of the primary outcome, and dyspnea at 12 months. The database-level hazard ratios (HRs) were pooled to calculate summary HRs by random-effects meta-analysis. Results: After propensity score matching among 31 290 propensity-matched pairs (median age group, 60-64 years; 29.3% women), 95.5% of patients took aspirin together with ticagrelor or clopidogrel. The 1-year risk of NACE was not significantly different between ticagrelor and clopidogrel (15.1% [3484/23 116 person-years] vs 14.6% [3290/22 587 person-years]; summary HR, 1.05 [95% CI, 1.00-1.10]; P = .06). There was also no significant difference in the risk of all-cause mortality (2.0% for ticagrelor vs 2.1% for clopidogrel; summary HR, 0.97 [95% CI, 0.81-1.16]; P = .74) or ischemic events (13.5% for ticagrelor vs 13.4% for clopidogrel; summary HR, 1.03 [95% CI, 0.98-1.08]; P = .32). The risks of hemorrhagic events (2.1% for ticagrelor vs 1.6% for clopidogrel; summary HR, 1.35 [95% CI, 1.13-1.61]; P = .001) and dyspnea (27.3% for ticagrelor vs 22.6% for clopidogrel; summary HR, 1.21 [95% CI, 1.17-1.26]; P < .001) were significantly higher in the ticagrelor group. Conclusions and Relevance: Among patients with ACS who underwent PCI in routine clinical practice, ticagrelor, compared with clopidogrel, was not associated with significant difference in the risk of NACE at 12 months. Because the possibility of unmeasured confounders cannot be excluded, further research is needed to determine whether ticagrelor is more effective than clopidogrel in this setting.


Assuntos
Síndrome Coronariana Aguda/cirurgia , Clopidogrel/efeitos adversos , Intervenção Coronária Percutânea , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Ticagrelor/efeitos adversos , Síndrome Coronariana Aguda/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Aspirina/administração & dosagem , Estudos de Casos e Controles , Causas de Morte , Clopidogrel/administração & dosagem , Bases de Dados Factuais/estatística & dados numéricos , Dispneia/induzido quimicamente , Feminino , Hemorragia/induzido quimicamente , Humanos , Isquemia/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Metanálise em Rede , Pontuação de Propensão , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Recidiva , República da Coreia , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Ticagrelor/administração & dosagem , Estados Unidos
4.
Medicine (Baltimore) ; 99(19): e19969, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384446

RESUMO

Although previous clinical trials demonstrated that ticagrelor could reduce cardiovascular events and mortality versus clopidogrel in patients with acute coronary syndrome (ACS), the real-world evidence of its clinical impacts on East Asian Diabetic population has rarely been investigated.Between November 2013 and June 2015, 1534 patients were recruited into the Acute Coronary Syndrome-Diabetes Mellitus Registry of the Taiwan Society of Cardiology (TSOC ACS-DM registry). After propensity score matching, a total of 730 patients undergoing successful revascularization and discharged on ticagrelor (N = 365) or clopidogrel (N = 365) were analyzed. The primary and secondary endpoints were all-cause mortality and re-hospitalization, respectively. The all-cause death associated with ticagrelor vs clopidogrel was 3.6% vs 7.4% (adjusted hazard ratio (HR) 0.34 [0.15-0.80]; P = .0138) at 24 months. The re-hospitalization rate at 24 months was 38.9% vs 39.2% (P = .3258).For diabetic patients with ACS, ticagrelor provided better survival benefit than clopidogrel without an increase of re-hospitalization in 24 months after successful percutaneous coronary intervention. This study in real-world circumstance provided valuable complementary data to externally validate platelet inhibition and patient outcomes (PLATO) finding especially in Asian diabetic population.


Assuntos
Síndrome Coronariana Aguda , Clopidogrel , Diabetes Mellitus/epidemiologia , Intervenção Coronária Percutânea , Ticagrelor , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/terapia , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Pontuação de Propensão , Sistema de Registros , Prevenção Secundária/métodos , Prevenção Secundária/estatística & dados numéricos , Taiwan/epidemiologia , Ticagrelor/administração & dosagem , Ticagrelor/efeitos adversos , Resultado do Tratamento
5.
J Food Sci ; 85(4): 1285-1291, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32157685

RESUMO

Green tea is widely consumed as a beverage and/or dietary supplement worldwide, resulting in the difficulty to avoid the comedication with ticagrelor for acute coronary syndrome (ACS) patients receiving antiplatelet therapy. This study was designed to investigate the effect of the most abundant content in green tea, tea polyphenols on the oral and intravenous pharmacokinetics of ticagrelor in rats and its in vitro metabolism. Rats were orally treated with either saline or tea polyphenol extracts (TPEs) dissolved in saline once daily for 6 consecutive days. On day 6, after the last dose of saline or TPE, ticagrelor was given to the rats orally or intravenously. Plasma samples were collected for pharmacokinetic analysis. Human liver and intestinal microsomes were then used to investigate the inhibition by TPE, as well as its major constituents on the metabolism of ticagrelor to its two metabolites, AR-C124910XX and AR-C133913XX. Apparent kinetic constants and inhibition potency (IC50 ) for each metabolic pathway of each compound were estimated. Oral study indicated that exposure of ticagrelor and AR-C124910XX was significantly decreased after TPE administration, while no significant differences were observed in pharmacokinetic parameters after intravenous administration of ticagrelor. TPE effectively inhibited the metabolism of ticagrelor in vitro, with epigallocatechin-3-gallate as the major constituent responsible for the observed inhibitory effects in human liver microsomes and intestinal microsomes (IC50 = 4.23 ± 0.18 µM). Caution should be taken for ACS patients receiving ticagrelor therapy with daily drinking of green tea. PRACTICAL APPLICATION: Potential interactions between tea polyphenols and ticagrelor were revealed for the first time. Results can provide suggestions for clinicians to optimize the dosing of ticagrelor while they are in the face of ACS patients receiving ticagrelor therapy, who also take green tea or its related products in their daily life.


Assuntos
Microssomos Hepáticos/efeitos dos fármacos , Inibidores da Agregação de Plaquetas/farmacocinética , Polifenóis/farmacocinética , Chá/química , Ticagrelor/farmacocinética , Adenosina/análogos & derivados , Administração Intravenosa , Administração Oral , Animais , Catequina/análogos & derivados , Masculino , Microssomos Hepáticos/metabolismo , Inibidores da Agregação de Plaquetas/administração & dosagem , Polifenóis/administração & dosagem , Polifenóis/química , Ratos , Ticagrelor/administração & dosagem , Ticagrelor/metabolismo
6.
J Gastroenterol Hepatol ; 35(10): 1720-1730, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32154936

RESUMO

BACKGROUND AND AIM: The presence and severity of upper gastrointestinal mucosal lesions have not been evaluated using esophagogastroduodenoscopy (EGD) in patients receiving ticagrelor plus aspirin or alone after myocardial revascularization. We assessed upper gastrointestinal mucosal injury and the use of proton pump inhibitors (PPIs) in patients receiving 1 year of antiplatelet therapy after coronary artery bypass grafting (CABG). METHODS: In this single-center prospective substudy of a randomized trial, 231 patients completing 1-year antiplatelet therapy (ticagrelor 90 mg twice daily plus aspirin 100 mg once daily, ticagrelor 90 mg twice daily, or aspirin 100 mg once daily, in 81, 80, and 70 patients, respectively) after CABG underwent 13 C urea breath testing and EGD. Gastroduodenal lesions were assessed by modified Lanza score, and reflux esophagitis was evaluated according to Los Angeles classification. Additionally, at least one ulcer ≥ 5 mm was separately analyzed. RESULTS: Among 231 patients, EGD showed 28 (12.1%) with ulcers ≥ 5 mm, which were detected in 13.6% (11/81) of ticagrelor plus aspirin recipients, 8.8% (7/80) of ticagrelor recipients, and 14.3% (10/70) of aspirin recipients, and 24 (10.4%) had reflux esophagitis. Eighty-eight (38.1%) patients had a positive 13 C urea breath testing after 1 year of treatment, and one patient received eradication therapy during follow up. Nineteen (8.2%) patients received a PPI for ≥ 6 months. CONCLUSIONS: Severe upper gastrointestinal mucosal lesions were more frequently observed in patients treated with ticagrelor plus aspirin and aspirin monotherapy than in patients treated with ticagrelor monotherapy for 1 year post-CABG. Prophylactic use of PPIs might be inadequate.


Assuntos
Aspirina/efeitos adversos , Ponte de Artéria Coronária , Mucosa Gástrica/efeitos dos fármacos , Mucosa Gástrica/patologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Úlcera Gástrica/induzido quimicamente , Úlcera Gástrica/patologia , Ticagrelor/efeitos adversos , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/patologia , Síndrome Coronariana Aguda/cirurgia , Idoso , Aspirina/administração & dosagem , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Prospectivos , Inibidores da Bomba de Prótons/administração & dosagem , Úlcera Gástrica/prevenção & controle , Ticagrelor/administração & dosagem , Fatores de Tempo
7.
BMC Cardiovasc Disord ; 20(1): 109, 2020 03 05.
Artigo em Inglês | MEDLINE | ID: mdl-32138662

RESUMO

BACKGROUND: Patients with coronary chronic total occlusion (CTO) require effective antiplatelet therapy after percutaneous coronary intervention (PCI). Ticagrelor has more pronounced platelet inhibition than clopidogrel. However, the most appropriate dose of ticagrelor in East Asian populations remains unclear. METHOD: We compared ticagrelor (180 mg loading dose, 90 mg twice daily thereafter and 120 mg loading dose, 60 mg twice daily thereafter) and clopidogrel (300 mg loading dose, 75 mg daily thereafter) for prevention of cardiovascular events in 525patients with CTO undergoing PCI. RESULTS: The rate of in-hospital major adverse cardiac and cerebral events (MACCE) was not different between the groups. At 1-year follow-up, target vessel revascularization (TVR) in both ticagrelor groups were significantly lower than that in the clopidogrel group (p = 0.047); TVR was significantly decreased in 60 mg ticagrelor compared to standard dose clopidogrel (p = 0.046). At 1-year follow-up, overall MACCE in both ticagrelor groups were significantly lower than that in the clopidogrel group (p = 0.023). Kaplan-Meier analysis showed MACCE-free survival was significantly higher in both ticagrelor groups than in the clopidogrel group (p = 0.024). During hospitalization, minor bleeding was significant increased in the 90 mg ticagrelor group (p = 0.021). At 1-year follow-up, risk of major and minor bleeding were significantly increased in the 90 mg ticagrelor group. CONCLUSION: In East Asian patients with CTO undergoing PCI, 60 mg ticagrelor was as effective as 90 mg, at the same time significantly reduced risk of bleeding.


Assuntos
Clopidogrel/administração & dosagem , Oclusão Coronária/terapia , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Ticagrelor/administração & dosagem , Idoso , Grupo com Ancestrais do Continente Asiático , China/epidemiologia , Doença Crônica , Clopidogrel/efeitos adversos , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/etnologia , Oclusão Coronária/mortalidade , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
8.
JACC Cardiovasc Interv ; 13(5): 634-646, 2020 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-32139222

RESUMO

OBJECTIVES: This study assessed the ability of the dual-antiplatelet therapy (DAPT) score in stratifying ischemic and bleeding risk in a contemporary percutaneous coronary intervention (PCI) population. BACKGROUND: The DAPT score is recommended by guidelines as a tool to stratify ischemic and bleeding risk. Its utility in contemporary PCI is unknown. METHODS: The study studied patients in GLOBAL LEADERS (A Clinical Study Comparing Two Forms of Anti-platelet Therapy After Stent Implantation) who were free of major ischemic and bleeding events and adhered to antiplatelet strategy during the first year after PCI. The primary ischemic endpoint was the composite of myocardial infarction or stent thrombosis. The primary bleeding endpoint was Bleeding Academic Research Consortium type 3 or 5. Outcomes from 12 to 24 months after PCI were compared according to the DAPT score. RESULTS: Of 11,289 patients that were event-free after the first year, 6,882 and 4,407 patients had low (<2) and high (≥2) DAPT scores, respectively. Compared with a low DAPT score, patients with a high DAPT score had a higher rate of the composites of myocardial infarction or stent thrombosis (0.70% vs. 1.55%; p < 0.0001). The rate of Bleeding Academic Research Consortium type 3 or 5 bleeding was 0.54% and 0.30% in the low and high DAPT score groups, respectively (p = 0.058). The effect of ticagrelor versus aspirin monotherapy on primary ischemic and bleeding endpoints during the second year were no different among the 2 groups. CONCLUSIONS: The DAPT score can stratify ischemic but not bleeding risk in a contemporary PCI population during the second year. The score did not provide additional value for selection of antiplatelet strategy beyond the first year.


Assuntos
Síndrome Coronariana Aguda/terapia , Regras de Decisão Clínica , Doença da Artéria Coronariana/terapia , Trombose Coronária/prevenção & controle , Terapia Antiplaquetária Dupla , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Stents , Ticagrelor/administração & dosagem , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Idoso , Tomada de Decisão Clínica , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/etiologia , Esquema de Medicação , Terapia Antiplaquetária Dupla/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação de Plaquetas/efeitos adversos , Valor Preditivo dos Testes , Intervalo Livre de Progressão , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Ticagrelor/efeitos adversos , Fatores de Tempo
10.
Cardiovasc Drugs Ther ; 34(2): 199-208, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32006144

RESUMO

PURPOSE: Although current guidelines recommend ticagrelor in addition to aspirin as the antiplatelet strategy for medically managed acute coronary syndrome (MMACS) patients, clinical evidence specific to this special population is lacking. Whether potent oral P2Y12 inhibitors should be used in MMACS patients is still under debate. METHODS: We conducted a comprehensive search in PubMed, Embase, Web of Science, and Cochrane Library to identify studies exploring the efficacy or safety of ticagrelor and prasugrel versus clopidogrel or placebo in MMACS patients. The primary efficacy endpoint was major adverse cardiovascular events (MACE) defined by each study, and the safety endpoint was TIMI non-CABG major bleeding. RESULTS: A total of 6102 records were screened, and 4 studies including 46,346 patients were finally included. The use of potent oral P2Y12 inhibitors significantly lowers the risk of MACE compared with clopidogrel (HR: 0.90; 95% CI: 0.82-0.98; P = .018; I2 = 0%). A significant reduction in risks of all-cause death and myocardial infarction was also observed with the use of potent oral P2Y12 inhibitors compared with clopidogrel. No significant difference in risks of stroke or TIMI non-CABG major bleeding (HR: 1.24; 95% CI: 0.90-1.73; P = .191; I2 = 0%) was observed between potent oral P2Y12 inhibitors and clopidogrel. CONCLUSION: Potent oral P2Y12 inhibitors, especially ticagrelor, decrease the risk of ischemic events in MMACS patients as compared with clopidogrel, without significantly increasing major bleeding.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Clopidogrel/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Ticagrelor/administração & dosagem , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico , Administração Oral , Idoso , Clopidogrel/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Medição de Risco , Fatores de Risco , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
11.
Curr Vasc Pharmacol ; 18(3): 294-301, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31124422

RESUMO

BACKGROUND: Dual antiplatelet therapy (DAPT) with aspirin and ticagrelor is recommended for at least 12 months in patients after an acute coronary syndrome (ACS). However, its underuse and premature discontinuation are common in clinical practice. We aimed to investigate the impact of a dedicated follow-up strategy with clinical visits and counselling on adherence levels to ticagrelor in patients after ACS. METHODS: PROGRESS (PROmotinG dual antiplatelet therapy adheREnce in the setting of acute coronary Syndromes) is a prospective, randomized trial enrolling 400 ACS patients treated with ticagrelor. Patients were randomized to be followed-up in a dedicated outpatient clinic (In-person follow-up group, [IN-FU], n=200), or with scheduled for phone interviews only (Telephone follow-up group [TEL-FU], n=200), to assess ticagrelor adherence and related complications. DAPT disruption was defined as an interruption of the administration of the drug due to complications or other reasons of non-adherence, and divided according to the duration into short (1-5 days), temporary (6-30 days) and permanent (≥30 days) disruption. The primary endpoint was the rate of DAPT disruption at 1-year follow-up. RESULTS: The rate of ticagrelor disruption at 1 year follow-up was higher in the TEL-FU group than in the IN-FU group (19.6 vs 5.5%; p<0.0001). The IN-FU group reported a significantly lower rate of short (3.0 vs 8.5%; p=0.012) and permanent (2.0 vs 9.6%; p=0.012) disruption than TEL-FU group. The rate of major bleeding did not differ significantly between the 2 groups (p=0.450). CONCLUSION: The PROGRESS trial showed a net reduction in DAPT disruption in patients followed-up with clinical (in-person) follow-up visits in a dedicated outpatient clinic compared with those scheduled for phone interviews only.


Assuntos
Síndrome Coronariana Aguda/terapia , Agendamento de Consultas , Adesão à Medicação , Ambulatório Hospitalar , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/administração & dosagem , Telefone , Ticagrelor/administração & dosagem , Síndrome Coronariana Aguda/diagnóstico por imagem , Idoso , Aspirina/administração & dosagem , Esquema de Medicação , Terapia Antiplaquetária Dupla , Feminino , Hemorragia/induzido quimicamente , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Prospectivos , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
12.
J Neurointerv Surg ; 12(2): 148-155, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31273075

RESUMO

BACKGROUND: Thromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens. OBJECTIVE: To explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures. METHODS: We performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included. RESULTS: Of 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89). CONCLUSIONS: Evidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , Stents Metálicos Autoexpansíveis/tendências , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/fisiopatologia , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Feminino , Humanos , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/administração & dosagem , Cloridrato de Prasugrel/efeitos adversos , Stents Metálicos Autoexpansíveis/efeitos adversos , Ticagrelor/administração & dosagem , Ticagrelor/efeitos adversos , Resultado do Tratamento
13.
J Cardiovasc Pharmacol Ther ; 25(2): 158-163, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31550912

RESUMO

BACKGROUND: Critical limb-threatening ischemia (CLTI) is associated with an increased risk of major adverse limb events and mortality. High on-treatment platelet reactivity (HPR) is associated with an increased risk of ischemic events, while low on-treatment platelet reactivity (LPR) is associated with an increased risk of bleeding. This study investigates the frequency with which patients with CLTI on clopidogrel or ticagrelor achieve a "therapeutic window" (TW) of platelet inhibition. METHODS: Data from the "Switch To Ticagrelor in Critical Limb Ischemia Anti-Platelet Study" were assessed retrospectively to determine the incidence of TW of on-treatment platelet reactivity in 50 consecutive patients with CLTI (mean age: 65.2 ± 10.5 years, 54% male). The data included 4 measurements of patients' platelet reactivity using the VerifyNow P2Y12 Assay: baseline and steady state platelet reactivity on clopidogrel 75 mg daily and on ticagrelor 90 mg twice daily. RESULTS: At baseline, 46% of patients on clopidogrel were within TW of on-treatment platelet reactivity compared to 10% of patients on ticagrelor (P < .0001). At steady state, 42% of patients on clopidogrel were within the TW compared to 10% of patients on ticagrelor (P < .0001). Patients on ticagrelor exhibited higher rates of LPR compared to those on clopidogrel at baseline as well as at steady state (baseline 88% vs 18%, steady state 88% vs 28%; P < .0001). CONCLUSION: Although ticagrelor has been proposed as an alternative for patients with HPR on clopidogrel, the current study observes an excess of platelet inhibition with ticagrelor in most patients with CLTI at a dose of 90 mg twice daily.


Assuntos
Clopidogrel/administração & dosagem , Isquemia/tratamento farmacológico , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , Agregação Plaquetária/efeitos dos fármacos , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Ticagrelor/administração & dosagem , Idoso , Clopidogrel/efeitos adversos , Estado Terminal , Esquema de Medicação , Monitoramento de Medicamentos , Feminino , Humanos , Isquemia/sangue , Isquemia/diagnóstico , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Inibidores da Agregação de Plaquetas/efeitos adversos , Testes de Função Plaquetária , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
14.
Ann Thorac Surg ; 109(4): e289-e291, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31302083

RESUMO

The optimum antithrombotic strategy before open heart surgery in patients with recently implanted coronary stents has not been clearly established because of lack of clinical evidence. This report describes a case of stent thrombosis in a patient who discontinued a P2Y12 inhibitor (ticagrelor) for 3 days before coronary artery bypass grafting. The period of withdrawal of antiplatelet drugs before coronary artery bypass grafting should be minimized in patients with recently implanted drug-eluting coronary stents to prevent stent thrombosis.


Assuntos
Ponte de Artéria Coronária , Inibidores da Agregação de Plaquetas/administração & dosagem , Complicações Pós-Operatórias/etiologia , Stents/efeitos adversos , Trombose/etiologia , Ticagrelor/administração & dosagem , Idoso , Humanos , Masculino , Fatores de Tempo , Suspensão de Tratamento
15.
Platelets ; 31(3): 337-343, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31043110

RESUMO

In patients with acute coronary syndrome (ACS), treatment using ticagrelor demonstrated significant ischemic benefits over clopidogrel; however, it was associated with increased bleeding complications leading to frequent de-escalation to clopidogrel. The objective of the present study was to investigate the efficacy and safety of de-escalation in early and late phase after percutaneous coronary intervention (PCI). We performed a retrospective study of 4678 ACS patients from March 2016 to April 2017 who initially received ticagrelor then de-escalated to clopidogrel and categorized them into Group 1: early phase (1-30 days) and Group 2: late phase (>30 days-1 year) switching groups. The primary efficacy endpoints included cardiovascular death, definite/probable stent thrombosis, myocardial infarction, unplanned revascularization, and stroke. The safety endpoint was Bleeding Academic Research Consortium classification 3 or 5 bleeding events within 1 year after PCI. The incidence of switching occurred in 1019 patients; 380 (37.3%) in Group 1 (median 14 days, interquartile range 4-30 days) versus 639 (62.7%) in Group 2 (median 180 days, interquartile range 90-270 days). The ischemic endpoints occurred in 53 (13.9%) patients in Group 1 versus 35 (5.4%) in Group 2 (HR 1.93,95%CI 1.22-3.08, p < .0001). There were no significant differences of major bleeding events (HR 0.91; 95%CI, 0.58-1.43, p = .90) seen between the groups. The main cause for switching between the two groups was due to BARC 1 or 2 bleeding types. Early de-escalation from ticagrelor to clopidogrel during the initial 30 days after ACS was associated with higher risk of ischemic events when compared with switching beyond 30 days.


Assuntos
Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/tratamento farmacológico , Clopidogrel/uso terapêutico , Substituição de Medicamentos , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/cirurgia , China , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Eletrocardiografia , Seguimentos , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Estimativa de Kaplan-Meier , Angiografia por Ressonância Magnética , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Estudos Retrospectivos , Ticagrelor/administração & dosagem , Ticagrelor/efeitos adversos , Ticagrelor/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
16.
Eur J Clin Pharmacol ; 76(2): 257-265, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31773191

RESUMO

PURPOSE: Use of oral antiplatelets (OAPs) is essential for preventing thrombotic events in patients with acute coronary syndrome (ACS). Effects of clopidogrel, prasugrel, and ticagrelor may be enhanced due to pharmacodynamic interactions, but as CYP substrates, they are prone to pharmacokinetic interactions too. The aim was to study polypharmacy in ACS patients following hospital discharge. METHODS: This observational drug utilization study linked patient-level data from nationwide registers. The study population consisted of adult ACS patients discharged from Finnish hospitals in 2009-2013. Logistic regression was used to model the probability of drug-drug interactions with odd ratios for predefined predictors such as age, gender, and ACS type. RESULTS: In the cohort of 54,416 ACS patients, 91% of those treated with OAP received clopidogrel. Of clopidogrel-treated patients, 12% purchased warfarin at least once while on clopidogrel treatment. Old age, male sex, ST-elevation myocardial infarction as index event, and a history of previous ACS events were associated with an increased risk of warfarin-OAP interaction (p < 0.001 for all). Ibuprofen, and serotonergic drugs tramadol, citalopram, and escitalopram were the next most common drugs causing pharmacodynamic interactions. In general, concomitant use of drugs known to cause pharmacokinetic interactions was rare, but both esomeprazole and omeprazole were prescribed in more than 6% of clopidogrel-treated patients. CONCLUSIONS: Warfarin and ibuprofen were the most commonly used concomitant medications causing pharmacodynamic interactions and potentially increasing the risk of bleeding in OAP-treated patients. Esomeprazole and omeprazole were used in clopidogrel-treated patients although there are alternatives available for gastric protection.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , Polimedicação , Administração Oral , Adulto , Idoso , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Clopidogrel/farmacocinética , Estudos de Coortes , Interações Medicamentosas , Feminino , Finlândia , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/farmacocinética , Cloridrato de Prasugrel/administração & dosagem , Cloridrato de Prasugrel/efeitos adversos , Cloridrato de Prasugrel/farmacocinética , Estudos Retrospectivos , Ticagrelor/administração & dosagem , Ticagrelor/efeitos adversos , Ticagrelor/farmacocinética
17.
Pharmacogenomics ; 21(1): 33-42, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31849282

RESUMO

Aim: This study aimed to evaluate the cost-effectiveness of CYP2C19 loss-of-function(LOF) allele-guided antiplatelet therapy compared with the universal use of clopidogrel or ticagrelor among Chinese patients with acute coronary syndrome undergoing percutaneous coronary intervention. Methods: A two-part cost-effectiveness model comprising of a 1-year decision tree and a long-term Markov model was utilized to simulate outcomes of three treatment strategies: universal use of clopidogrel (75 mg daily) or universal use of ticagrelor 90 mg twice daily for all patients and CYP2C19 LOF-guided therapy (LOF allele carriers receiving ticagrelor, LOF allele noncarriers receiving clopidogrel). Model outcomes included quality-adjusted life years (QALYs) gained, direct medical costs and incremental cost-effectiveness ratios (ICERs). ICERs less than one-time gross domestic product per capita in China 59,660 yuan/QALY were considered cost-effective. Results: Base-case analysis showed 'universal ticagrelor use' was cost-effective for an ICER of 33,875 yuan per QALY gained compared with 'universal clopidogrel use' of which gained a 1.6932 QALYs at lowest life-long cost of 2450 yuan. CYP2C19 LOF-guided therapy had an effectiveness of 1.6975 QALYs at a cost of 2812 yuan, for an ICER of 84,118 yuan per QALY gained relative to 'universal clopidogrel use'. Sensitivity analysis demonstrated that base-case results were significantly affected by five factors: the risk ratio of 'non-fatal myocardial infarction', 'non-fatal stroke' and 'cardiovascular death' in ticagrelor versus clopidogrel and the annual costs of clopidogrel and ticagrelor. According to the results of Monte Carlo simulation, when willing to pay is about 32,000 yuan, patients willing to receive clopidogrel or ticagrelor are approximately equal. Conclusion: Optimal antiplatelet treatment is affected by lots of factors. The results of our study demonstrated that 'universal ticagrelor use' was cost-effective compared with 'universal clopidogrel use' for Chinese acute coronary syndrome patients with percutaneous coronary intervention.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Análise Custo-Benefício , Citocromo P-450 CYP2C19/genética , Inibidores da Agregação de Plaquetas/administração & dosagem , Síndrome Coronariana Aguda/economia , Síndrome Coronariana Aguda/genética , Síndrome Coronariana Aguda/patologia , China/epidemiologia , Clopidogrel/administração & dosagem , Clopidogrel/economia , Feminino , Humanos , Mutação com Perda de Função/genética , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Ticagrelor/administração & dosagem , Ticagrelor/economia
19.
Eur Heart J Cardiovasc Pharmacother ; 6(1): 31-42, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31511896

RESUMO

AIMS: The aim of the present study was to establish the safety and efficacy profile of prasugrel and ticagrelor in real-life acute coronary syndrome (ACS) patients with renal dysfunction. METHODS AND RESULTS: All consecutive patients from RENAMI (REgistry of New Antiplatelets in patients with Myocardial Infarction) and BLEEMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registries were stratified according to estimated glomerular filtration rate (eGFR) lower or greater than 60 mL/min/1.73 m2. Death and myocardial infarction (MI) were the primary efficacy endpoints. Major bleedings (MBs), defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety endpoint. A total of 19 255 patients were enrolled. Mean age was 63 ± 12; 14 892 (77.3%) were males. A total of 2490 (12.9%) patients had chronic kidney disease (CKD), defined as eGFR <60 mL/min/1.73 m2. Mean follow-up was 13 ± 5 months. Mortality was significantly higher in CKD patients (9.4% vs. 2.6%, P < 0.0001), as well as the incidence of reinfarction (5.8% vs. 2.9%, P < 0.0001) and MB (5.7% vs. 3%, P < 0.0001). At Cox multivariable analysis, potent P2Y12 inhibitors significantly reduced the mortality rate [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.54-0.96; P = 0.006] and the risk of reinfarction (HR 0.53, 95% CI 0.30-0.95; P = 0.033) in CKD patients as compared to clopidogrel. The reduction of risk of reinfarction was confirmed in patients with preserved renal function. Potent P2Y12 inhibitors did not increase the risk of MB in CKD patients (HR 1.00, 95% CI 0.59-1.68; P = 0.985). CONCLUSION: In ACS patients with CKD, prasugrel and ticagrelor are associated with lower risk of death and recurrent MI without increasing the risk of MB.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Taxa de Filtração Glomerular , Rim/fisiopatologia , Infarto do Miocárdio/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , Cloridrato de Prasugrel/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Insuficiência Renal Crônica/fisiopatologia , Ticagrelor/administração & dosagem , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Recidiva , Sistema de Registros , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Ticagrelor/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
20.
J Thromb Thrombolysis ; 49(1): 145-148, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31471774

RESUMO

Pregnancy-associated acute myocardial infarction is a rare condition usually occurring during the third trimester of pregnancy, and associated with three-to-four-fold higher mortality compared with rates among non-pregnant women of the same age. As in non-pregnant women, in cases of ST elevation myocardial infarction, the most effective treatment is primary percutaneous coronary intervention with stent implantation. Unfortunately, management of these patients could be challenging because little is known about the optimal medical strategy; the potential teratogenic effects of the third generation thienopyridines are not fully established too. In fact current guidelines do not provide enough recommendations about tailoring dual antiplatelet therapy prescription according to ischemic profile of the pregnant patients. Moreover, the bleeding risk class of cesarean delivery/hysterectomy is not stated in current consensus documents. We report the second pregnancy-associated acute myocardial infarction case successfully treated with ticagrelor before and after primary percutaneous coronary intervention with drug eluting stent implantation on left coronary artery, but also the first report on use of bridging antiplatelet therapy with tirofiban during temporary withdrawal of ticagrelor because of a C-section.


Assuntos
Nascimento Vivo , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Ticagrelor/administração & dosagem , Tirofibana/administração & dosagem , Adulto , Cesárea , Feminino , Humanos , Gravidez
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA