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Antiplatelet therapy in long-term risk reduction after myocardial infarction

22 May, 15 | by Alistair Lindsay

The activated platelet is central to development of ischemic cardiovascular events. Guidelines recommend treatment with a P2Y12 receptor antagonist for 1-year after myocardial infarction (MI) to reduce the risk of recurrent events.  The PEGASUS trial sought to determine the impact of using the P2Y12 antagonist ticagrelor as part of long-term therapy after MI.  In this trial, a total of 21,162 clinically stable patients with a MI in the prior 1 to 3 years (median 18 months) were randomized in a 1:1:1 fashion to either placebo, ticagrelor 90mg twice daily, or ticagrelor 60mg twice daily.  All patients remained on aspirin and standard secondary prevention as tolerated.  Follow up was for a median of 33 months with the primary outcome being a composite of cardiovascular death, myocardial infarction, or stroke and the primary safety end-point of bleeding.  more…

Dual Antiplatelet Therapy Beyond 1-year after Percutaneous Coronary Interventions for Stable Coronary Artery Disease Results in Harm  

20 Dec, 14 | by Alistair Lindsay

The benefit of extended dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is uncertain. The ARTIC-Interruption Trial examined discontinuation of DAPT at 1-year after PCI vs continuation for an additional 6-18 months. The study randomized patients 1-year after PCI to continuation (N=635) or interruption (N=624) groups, and examined the primary composite endpoint of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization over a median follow-up of 17 months. No significant differences were observed between the treatment groups for the primary outcome (hazard ratio [HR] 1.17; 95% confidence interval [CI] 0.68–2.03]; p=0.58). Bleeding events (as defined by STEEPLE criteria) occurred significantly more frequently in the continuation group (HR 0.26; 95% CI 0.07–0.91; p=0.04) when major and minor bleeding events were combined. As this study was a follow on to an evaluation of antiplatelet regimens guided by platelet reactivity at the time of index PCI, there was variation in the type of DAPT between patients at randomization for this study. Furthermore, there was crossover between treatment arms that was not evaluated with an on-treatment analysis. more…

Stent type and interrupted anti-platelet therapy does not correlate with adverse events after non-cardiac surgeries

29 Dec, 13 | by Alistair Lindsay

Guidelines recommend delaying elective surgery in patients with drug eluting stent (DES) for one year after stent implantation to allow completion of 1 year of dual anti-platelet therapy (DAPT) without interruption.  This recommendation is based on expert consensus and results in several clinical questions, including whether it is preferable to use a bare metal stent (BMS) in patients with a potential for future surgery and whether this delay is excessive for patients considering surgery with other potential benefits (i.e. knee replacement in patients with life-limiting osteoarthritis).  Accordingly, the authors sought to understand the risk of major adverse cardiovascular events (MACE) following non-cardiac surgery among patients with coronary stents as a function of time since coronary stenting, stent type, and antiplatelet therapy during surgery. more…

Smoking and antiplatelet agents – smoke and mirrors or something more?

22 Nov, 13 | by Alistair Lindsay

Many antiplatelet therapies are prodrugs that require metabolic activation.  It has been hypothesized that smoking may activate this metabolic conversion for some antiplatelets (i.e. clopidogrel) more than others (i.e. prasugrel and ticagrelor).  In this systematic review and meta-analysis, the authors identified 9 randomized controlled trials of clopidogrel, prasugrel, or ticagrelor which examined outcomes among subgroups of smokers and non-smokers.  In the studies of clopidogrel, smokers on clopidogrel saw a 25% reduction in the primary composite outcome of cardiovascular death, MI, and stroke compared with patients in the control group (RR 0.75, 95% CI 0.67 – 0.83).  However, in non-smokers there was only an 8% reduction in the primary end point (RR 0.92, 95% CI 0.87 – 0.98).  Similarly, greater risk reduction was observed for smokers on ticagrelor or prasugrel when compared to clopidogrel while risk reduction was similar for all three drugs in non-smokers. more…

Longer antiplatelet therapy gives good DES outcomes

14 Oct, 08 | by Alistair Lindsay

Recently an excess of acute adverse coronary events has been reported among diabetic patients treated with drug eluting coronary stents (DES) who received short-term (<6 months) dual antiplatelet therapy (Circulation 2007;115:1440-55). more…

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