DYSLIPIDEMIA

CARDIOLOGY

Prophylactic Strategies for VTE in Gynecologic Cancer Patients

Watch This Video, Which Shed the Light on How It Is Safe and Effective to Use Anticoagulants in Gynecologic Cancer Patients Undergoing Major Surgery.

THROMBOSIS

Single Antiplatelet therapy: Insights on earlier use

Watch the video of Prof. Dominick Angiolillo, M.D., Ph.D., Professor &amp; Medical Director of the Cardiovascular Research Program, University of Florida College of Medicine, Jacksonville USA, sharing insights on recent studies that show an emphasis on the early use of single Antiplatelet therapy in PCI patients.

Clopidogrel as the standard of care for elective PCI: Findings from the Alpheus

Watch the video and get to know more on Alpheus trial. Since Percutaneous coronary intervention (PCI)-related myonecrosis is frequent and can affect the long-term prognosis of patients, then stronger platelet inhibition could potentially lower these events and make the PCI procedure safer.

<h2>Main Takeaway</h2>
<ul>
 <li>Risk for net adverse clinical events (NACE) was not significantly different&nbsp;between ticagrelor at 12 months compared with clopidogrel 
 <ul>
 <li>Study population: 62,580 patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) in routine clinical practice</li>
 </ul></li>
 <li>Ticagrelor was associated with&nbsp;higher risks for haemorrhagic events and dyspnoea&nbsp;vs clopidogrel</li>
</ul>
<h2>Why This Matters</h2>
<ul>
 <li>Recent observational studies&nbsp;question whether ticagrelor vs clopidogrel is associated with better outcomes&nbsp;in routine clinical practice 
 <ul>
 <li>Current guidelines: recommend ticagrelor with aspirin in preference to clopidogrel in patients with ACS</li>
 </ul></li>
</ul>
<h2>Study Design</h2>
Retrospective cohort study:&nbsp;183,579 patients (age range, 30-89 years) with ACS who underwent PCI and received ticagrelor or clopidogrel

Patients were matched using propensity score:
<ul>
 <li>Ticagrelor (n=31,290)</li>
 <li>Clopidogrel (n=31,290)</li>
</ul>
Primary endpoint:&nbsp;NACE at 12 months
<ul>
 <li>Ischaemic events 
 [recurrent acute myocardial infarction, revascularisation or ischaemic stroke]</li>
 <li>Haemorrhagic events 
 [haemorrhagic stroke or gastrointestinal bleeding]</li>
</ul>
Secondary outcomes:&nbsp;NACE or mortality, all-cause mortality, composite ischaemic events, composite haemorrhagic events, individual components of the primary outcome, dyspnoea at 12 months
<h2>Key Results</h2>
95.5% of matched patients used aspirin&nbsp;with ticagrelor or clopidogrel among the 31,290 propensity-matched pairs
The risk for NACE was not significantly different between ticagrelor and clopidogrel groups (HR, 1.05; 95% CI, 1.00-1.10; P=0.06)
<ul>
 <li>No significant difference was found between the 2 groups for: 
 <ul>
 <li>NACE or mortality (HR, 1.03; 95% CI, 0.98-1.08; P=0.21)</li>
 <li>Ischaemic events (HR, 1.03; 95% CI, 0.98-1.08; P=0.32)</li>
 <li>All-cause mortality (HR, 0.97; 95% CI, 0.81-1.16; P=0.74)</li>
 </ul></li>
 <li>Ticagrelor vs clopidogrel group showed a significantly higher risk for: 
 <ul>
 <li>Haemorrhagic events (HR, 1.35; 95% CI, 1.13-1.61; P=0.001)</li>
 <li>Dyspnoea (HR, 1.21; 95% CI, 1.17-1.26; P&lt;0.001)</li>
 </ul></li>
</ul>
<h2>Limitations</h2>
<ul>
 <li>The study did not include information on aspirin dosage, angiographic findings, or PCI procedure</li>
 <li>The burden of overall bleeding events could have been underestimated or overestimated</li>
 <li>Neither the proportion of patients who switched antiplatelet drugs nor its effects were quantified</li>
 <li>The effect of pre-treatment with an antiplatelet agent was not assessed</li>
 <li>The mortality rate might have been underestimated</li>
 <li>Patients who used prasugrel for dual antiplatelet therapy were not included</li>
</ul>

Reference

Ticagrelor vs Clopidogrel in ACS patients undergoing PCI in routine clinical practice

<h2>Main Takeaway</h2>
<ul>
 <li>Clopidogrel-based DAPT (CDAPT) was associated with a&nbsp;lower risk of bleeding events, major adverse cardiac and cerebral events&nbsp;(MACCE), and net adverse clinical events (NACE) than ticagrelor-based DAPT (TDAPT) 
 <ul>
 <li>Risks were similar between CDAPT and prasugrel-based DAPT (PDAPT)</li>
 </ul></li>
</ul>
<h2>Why This Matters</h2>
<ul>
 <li>The findings from this study support&nbsp;clopidogrel as a viable first-choice P2Y12 inhibitor for DAPT after PCI&nbsp;in an East-Asian patient population 
 <ul>
 <li>Recent European guidelines recommended potent P2Y12 inhibitors (ticagrelor and prasugrel) over clopidogrel in acute coronary syndromes, due to their rapid onset of action and strong antiplatelet activity 
 <ul>
 <li>Their safety and effectiveness in the East-Asian patients has often been questioned</li>
 </ul></li>
 </ul></li>
</ul>
<h2>Study Design</h2>
Retrospective study:&nbsp;57,197 patients in the South Korean HIRA database underwent PCI (from January 1 2014 to December 31 2016) and were treated with DAPT including aspirin and one of three P2Y12 inhibitors
<ul>
 <li>Clopidogrel + aspirin (CDAPT) (n=37,500)</li>
 <li>Ticagrelor + aspirin (TDAPT) (n=15,723)</li>
 <li>Prasugrel + aspirin (PDAPT) (n=3,974)</li>
</ul>
<h3>Key exclusion criteria:</h3>
<ul>
 <li>Age &lt;18 years as of the index date (n=6)</li>
 <li>History of PCI or CABG during the baseline period (n=3,434)</li>
 <li>Severe liver or chronic kidney disease (stage 4-5, n=1,315))</li>
 <li>Use of P2Y12 inhibitors during the baseline period (n=39,134)</li>
 <li>Use of oral antithrombotic agents (except low-dose aspirin) during the study period (n=19,849)</li>
</ul>
Key outcomes:&nbsp;the risk of bleeding events, risk of MACCE (a composite of all-cause death, myocardial infarction, stroke and revascularisation), risk of NACE, persistence and adherence rates
<h2>Key Results</h2>
The risk of bleeding events, MACCE, and NACE was significantly higher in the TDAPT group versus the CDAPT group, both at 1-year and in the prolonged periods
<ul>
 <li>Risk of bleeding event: 1-year hazard ratio (HR) = 1.37; 95% confidence interval (CI), 1.28–1.46; prolonged HR = 1.39; 95% CI, 1.31–1.47</li>
 <li>Risk of MACCE: 1-year HR = 1.10; 95% CI, 1.03–1.18; prolonged HR = 1.24; 95% CI, 1.16–1.31</li>
 <li>Risk of NACE: 1-year HR = 1.23; 95% CI, 1.18–1.29; prolonged HR = 1.31; 95% CI, 1.25–1.36</li>
 <li>No significant differences were reported for the risk of bleeding events, MACCE, and NACE between the PDAPT and CDAPT groups (1-year and prolonged periods)</li>
</ul>
The&nbsp;use of clopidogrel correlated with better adherence to DAPT&nbsp;than potent P2Y12 inhibitors
<ul>
 <li>34.9% of patients remained on CDAPT until the end of the prolonged period,&nbsp;whereas only 7.8% and 9.2% remained on TDAPT and PDAPT, respectively</li>
</ul>
<h2>Limitations</h2>
<ul>
 <li>Any association between P2Y12 inhibitors and clinical outcomes should be interpreted cautiously, owing to the observational nature of the study</li>
 <li>There was a lack of information regarding lesion complexity and location at index PCI, baseline laboratory findings, and cardiac function</li>
 <li>The information bias from voluntary/involuntary miscoding may lead to underestimation or overestimation of the outcomes</li>
 <li>The reporting of death was limited to in-hospital death</li>
 <li>It is difficult to generalise study findings in ethnic groups other than the East-Asian populations</li>
 <li>Reasons for P2Y12 inhibitor discontinuation were not identified</li>
</ul>

Is Clopidogrel a viable first choice P2Y12 inhibitor for DAPT after PCI?

<h2>Main Takeaway</h2>
A real-word study of Taiwanese patients with AMI undergoing PC
<ul>
 <li>Showed a comparable 1-year cardiovascular outcome&nbsp;with standard ticagrelor treatment 3 months after the event of AMI</li>
 <li>Didn’t report statistically significant differences in:
 <ul>
 <li>Hazard risk of death</li>
 <li>AMI admission</li>
 <li>Major adverse</li>
 <li>Cardiovascular events (MACE) 
 &nbsp;</li>
 </ul></li>
 <li>Didn’t show a difference in the risk of bleeding,&nbsp;including major or clinically relevant non-major bleeding</li>
</ul>

<h2>Why This Matters</h2>
<ul>
 <li>Bleeding risks could be reduced&nbsp;P2Y12 inhibitor de-escalation approach is considered by physicians to reduce additional bleeding risks</li>
 <li>Current studies are not enough&nbsp;Despite recent clinical studies, there’s limited and conflicting evidence on de-escalation strategies. This study aimed to assess the effect of de-escalated P2Y12 inhibitor switching in DAPT on MACE in patients with AMI undergoing PCI;</li>
</ul>

<h2>Study Design</h2>
This retrospective and population-based cohort study utilized data from the Taiwan’s National Health Insurance Research Database (NHIRD).
Key Inclusion Criteria:
<ul>
 <li>Patients who were hospitalized with a primary diagnosis of AMI</li>
</ul>
Key Exclusion Criteria:
<ul>
 <li>Patients aged &lt;18 years, without identification of sex, or Taiwanese citizenship</li>
 <li>Patients not on heparin or antiplatelet therapy, or were only on aspirin therapy, or</li>
 <li>received antiplatelet agents other than ticagrelor at index of AMI</li>
 <li>Patients who had a coronary artery bypass graft</li>
 <li>Death of the patient within 3 months after the index date of AMI</li>
</ul>
Key Outcomes:
<ul>
 <li>Death, AMI readmission, and MACE within one year during the follow-up period</li>
</ul>

<h2>Key Results</h2>
Number Of Participants
<ul>
 <li>10,100 patients were included (de-escalated DAPT group: n = 1,901; unchanged DAPT: n = 8,199)</li>
</ul>
Incidence Rates And Adjusted Hazard Ratio
<ul>
 <li>All-cause death&nbsp;(unchanged vs de-escalated DAPT group):&nbsp;Incidence&nbsp;= 2.42&nbsp;(95% confidence interval [CI]: 2.02–2.90) vs 2.89 (95% CI: 2.05–3.91);&nbsp;adjusted HR&nbsp;= 1.20&nbsp;(95% CI: 0.83–1.73; P = 0.336)</li>
 <li>AMI hospitalization&nbsp;(unchanged vs de-escalated DAPT group):&nbsp;Incidence&nbsp;= 3.28&nbsp;(95% CI: 2.81–3.83) vs 3.68 (95% CI: 2.75–4.88);&nbsp;adjusted HR&nbsp;= 1.12&nbsp;(95% CI: 0.80–1.56; P = 0.509)</li>
 <li>MACE&nbsp;(unchanged vs de-escalated DAPT group):&nbsp;Incidence&nbsp;= 4.72&nbsp;(95% CI: 4.13–5.36) vs 4.91 (95% CI: 3.80–6.26);&nbsp;adjusted HR&nbsp;= 1.04&nbsp;(95% CI: 0.78–1.39; P = 0.766)</li>
 <li>Major bleeding&nbsp;(unchanged vs de-escalated DAPT group):&nbsp;Incidence&nbsp;= 2.36&nbsp;(95% CI: 1.95–2.82) vs 2.12 (95% CI: 1.41–3.01);&nbsp;adjusted HR&nbsp;= 0.92&nbsp;(95% CI: 0.61–1.37; P = 0.669)</li>
</ul>

<h2>Limitations</h2>
<ul>
 <li>Patient information such as risk behaviors, diet, and physical activities are not available in the NHIRD.</li>
 <li>Hidden bias of medication selection was introduced as the study data was sourced from an administrative database.</li>
 <li>Missing clinical information, such as the severity of AMI at admission, might have induced non-differential misclassification bias.</li>
 <li>Study results might not be generalizable to other populations, as only Taiwanese patients were included in the analysis.</li>
</ul>

Effect of de-escalated P2Y12 inhibitor switching in dual antiplatelet therapy (DAPT)

Real-world adherence and persistence of dual antiplatelet therapy over two years in patients with coronary artery diseases
Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA)/clopidogrel showed a statistically significant better persistence vs ASA/ticagrelor and ASA/prasugrel. However, no statistically significant differences were seen in adherence to ASA/clopidogrel fixed dose combination (FDC) vs the use of two different pills.

<h2>Main Takeaway</h2>
<ul>
 <li>In this first study evaluating the difference in adherence between FDC vs each component taken as a separate pill, in patients with coronary artery disease treated with DAPT (at two years): 
 <ul>
 <li>No statistically significant difference was found between FDC of ASA/clopidogrel and the combination of the two ASA and clopidogrel pills taken separately (P = 0.0752).</li>
 <li>Adherence data were optimal for all types of DAPT analyzed (absolute value of adherence = 0.96).</li>
 </ul></li>
 <li>In this real-life analysis, persistence to therapy was observed to be better in the ASA/clopidogrel group vs the ASA/prasugrel and the ASA/ticagrelor groups (at two years). 
 <ul>
 <li>ASA/clopidogrel and ASA/clopidogrel (FDC) curves showed a statistically significant better persistence than ASA/prasugrel and ASA/ticagrelor curves (P &lt;0.001).</li>
 <li>However, the persistence data showed low adherence to the guidelines.</li>
 </ul></li>
</ul>

<h2>Why This Matters</h2>
<ul>
 <li>There is a lack of consensus regarding the optimal duration of DAPT for patients with coronary artery disease.</li>
 <li>Additionally, long-term adherence to DAPT remains a challenge in the management of patients with cardiovascular diseases in real-life, due to various factors like need for prolonged therapy, lack of proper prescription in the context of primary care, and the instructions provided at hospital discharge.</li>
 <li>This real-world study therefore, evaluated adherence and persistence over two years in patients receiving DAPT.</li>
</ul>

<h2>Study Design</h2>
<ul>
 <li>This non-interventional, retrospective study included all patients treated with DAPT in the Hospital of Pescara (Italy) utilizing data from the Hospital reimbursement database.</li>
 <li>The study population consisted of prevalent users of clopidogrel, ASA, prasugrel, and ticagrelor (administered as first-line therapy).</li>
</ul>

<h2>Key Results</h2>
<ul>
 <li>Overall, 519 patients treated with DAPT were included in the analysis (male = 83%; median age = 63; ASA/clopidogrel, n = 277; ASA/prasugrel, n = 77; ASA/ticagrelor, n = 57, and ASA/clopidogrel FDC, n = 108).</li>
 <li>Persistence (at two years): Persistence to therapy was observed to be better in the ASA/clopidogrel group vs the ASA/prasugrel and the ASA/ticagrelor groups 
 <ul>
 <li>ASA/clopidogrel and ASA/clopidogrel (FDC) curves showed a statistically significant better persistence than ASA/prasugrel and ASA/ticagrelor curves (P &lt;0.001).</li>
 <li>In total, 34 patients remained on ASA/clopidogrel and 18 patients remained on ASA/clopidogrel (FDC); while 1 patient each remained on ASA/prasugrel and ASA/ticagrelor therapies.</li>
 <li>Overall persistence data showed low adherence to the guidelines.</li>
 </ul></li>
 <li>Adherence (at two years): Adherence to therapy was optimal for all types of DAPT analyzed and remained stable over the study period 
 <ul>
 <li>Absolute value of adherence at two years was 0.96 and adherence ≥ 0.8 was observed in 94% of the patients</li>
 <li>ASA/prasugrel group had better adherence vs the other groups: Absolute value of adherence was 0.98; and adherence value ≥ 0.8 was seen in 97% of the patients</li>
 <li>FDC ASA/clopidogrel group had poor adherence vs the other groups: Absolute value of adherence was 0.94; and adherence value ≥ 0.8 was seen in 88% of the patients</li>
 <li>No statistically significant difference was found between FDC of ASA/clopidogrel and the combination of the two ASA and clopidogrel pills taken separately (P = 0.0752).</li>
 </ul></li>
</ul>

<h2>Limitations</h2>
<ul>
 <li>The reasons for non-persistence of therapy were not evaluated as the analysis was based on data from an administrative database.</li>
</ul>

Adherence and persistence analysis in patients treated with DAPT

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A Biologic option in severe Asthma

Severe Asthma Biomarker's

Eosinophils, lgE and FeNO - these clinical measurements can help us predict exacerbation risk and make informed biological selections1.

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