Early and Late Benefits of Prasugrel in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

Antman, Elliott M.; Wiviott, Stephen D.; Murphy, Sabina A.; Voitk, Jüri; Hasin, Yonathan; Widimský, Petr; Chandna, Harish; Macias, William L.; McCabe, Carolyn H.; Braunwald, Eugene

doi:10.1016/j.jacc.2008.04.002

Cited by 297 publications

(53 citation statements)

References 22 publications

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“…Moreover, we adjusted for important characteristics that were included in the Cox regression model, and we confirmed the unadjusted results. There is a precedent for landmark analyses in cardiology, 22,23 but because of the observational nature of landmark methodology, the findings should be interpreted in the context of cumulative survival analyses from randomization to the end of the study. The cut point of the landmark analysis was taken arbitrarily because it corresponds well to the period of maintenance therapy and secondary prevention.…”

Section: Discussionmentioning

confidence: 99%

High On-Treatment Platelet Reactivity as a Risk Factor for Secondary Prevention After Coronary Stent Revascularization

et al. 2014

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Stenting (ARCTIC) study. Whether results are different during the phase of secondary prevention starting after hospital discharge, when periprocedural events have been excluded, is unknown. Methods and Results-In ARCTIC, 2440 patients were randomized before coronary stenting to a strategy of platelet function monitoring (VerifyNow P2Y 12 /aspirin point-of-care assay) with drug adjustment in suboptimal responders to antiplatelet therapy or to a conventional strategy without monitoring and without drug or dose changes. We performed a landmark analysis starting at the time of hospital discharge evaluating the primary end point of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization through 1 year. After discharge, the primary end point occurred in 8.6% of patients in the monitoring arm and 7.9% in the conventional arm (hazard ratio, 1.105; 95% confidence interval, 0.835-1.461; P=0.48). Stent thrombosis or urgent revascularization occurred in 4.4% and 4.5% in the monitoring and conventional arms, respectively (P=0.99). There was no difference for any of the other ischemic end points. Major bleeding event rates were 1.8% in the monitoring arm and 2.8% in the conventional arm (P=0.11), whereas major or minor bleeding event rates were 2.3% and 3.4%, respectively (P=0.10). Conclusions-Detection of platelet hyper-reactivity by platelet function testing in patients undergoing coronary stenting with further therapeutic adjustment does not reduce ischemic recurrences after intervention. On-treatment platelet hyperreactivity cannot be considered as a risk factor requiring intervention for secondary prevention after percutaneous coronary revascularization. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00827411. Montalescot et al Landmark Analysis of ARCTIC 2137A lthough high on-treatment platelet reactivity in coronary patients is a marker of ischemic risk and biological information potentially available to adjust antiplatelet therapy, few randomized studies have been unable to establish differences in clinical outcomes with platelet function monitoring and treatment adjustment for coronary stenting compared with standard antiplatelet therapy without monitoring.1-3 The Assessment by a Double Randomization of a Conventional Antiplatelet Strategy Versus a Monitoring-Guided Strategy for Drug-Eluting Stent Implantation and of Treatment Interruption Versus Continuation One Year After Stenting (ARCTIC) study was unique in the fact that poor response to both aspirin and clopidogrel was searched for and treated, starting before intervention to prevent periprocedural and long-term events.3 No hint of improvement in ischemic outcomes was observed from randomization performed before the interventional procedure to the 1-year follow-up. Because randomization occurred early, most events were periprocedural myocardial infarctions. We wondered whether results would differ when considering patients only after hospital discharge when patients are on maintenance therapy t...

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Section: Discussionmentioning

confidence: 99%

High On-Treatment Platelet Reactivity as a Risk Factor for Secondary Prevention After Coronary Stent Revascularization

et al. 2014

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“…60 This is in contrast with novel P2Y12 receptor inhibitors, which was associated with increased rates of spontaneous bleeding over time. 61 Not surprisingly, the risk of bleeding rises with an increased number of antithrombotic agents. In one study of 21 443 elderly patients followed on average for 22 months after an acute MI, bleeding was 1.7 times more frequent with DAPT and 1.9 times more frequent with aspirin plus warfarin when compared with aspirin monotherapy.…”

Section: Major Bleedingmentioning

confidence: 99%

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Coronary Stenting

Faxon

Eikelboom

Berger

et al. 2011

Circ: Cardiovascular Interventions

126

113

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Abstract-The optimal regimen of the anticoagulant and antiplatelet therapies in patients with atrial fibrillation who have had a coronary stent is unclear. It is well recognized that "triple therapy" with aspirin, clopidogrel, and warfarin is associated with an increased risk of bleeding. National guidelines have not made specific recommendations, given the lack of adequate data. In choosing the best antithrombotic options for a patient, consideration needs to be given to the risks of stroke, stent thrombosis, and major bleeding. This executive summary describes these risks, provides specific recommendations concerning vascular access, stent choice, concomitant use of proton pump inhibitors, and the use and duration of triple therapy after stent placement, based on the risk assessment. (Circ Cardiovasc Interv. 2011;4:522-534.)Key Words: atrial fibrillation Ⅲ antithrombotic therapy Ⅲ warfarin Ⅲ triple therapy Ⅲ stent T he optimal regimen of the anticoagulant and antiplatelet therapies in patients with atrial fibrillation (AF) who have had a coronary stent is unclear. 1,2 It is estimated that 5-7% of patients undergoing percutaneous coronary interventions (PCI) have AF or other indications for chronic oral anticoagulant therapy. 3-5 These patients pose a significant dilemma for the interventional cardiologist because the combination of oral anticoagulants with aspirin and clopidogrel ("triple therapy") during follow-up has been reported to result in an increase risk of major bleeding. 6 Major bleeding is a serious complication that is associated with increased morbidity and mortality particularly when it occurs shortly after a stent procedure. 7,8 In one study among patients on triple therapy with aspirin, clopidogrel, and warfarin, major bleeding occurred in 4.7%, and approximately 50% of these patients died within 6 months. 9 Editorial see p 410The American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ ESC) guidelines have been cautious to recommend triple therapy (aspirin, clopidogrel, and oral anticoagulation) in patients with AF undergoing PCI due to the increased bleeding risk and limited information about the safety and efficacy of this treatment regimen. 10 Currently, the use of triple therapy is classified as a class IIb recommendation (may be considered) with a level of evidence C (expert opinion). 10,11 Recently, the ESC Working Group on Thrombosis published a consensus document on the management of these patients. 12,13 The authors conducted a careful review of the available studies and made a number of specific recommendations that have been supported by the ESC guidelines for the management of AF. 14 They tempered these recommendations since they were largely based on expert opinion. The current document provides a North American view of the issues and is the opinion of select experts in the United States and Canada. Because much of the background information has been previously published in the ESC consensus document, prior studies will not be extensively ...

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“…15 A landmark period of 48 hours was created. There were 28 deaths within 48 hours of randomization; these patients were excluded from multivariable modeling.…”

Section: Association Of Sustained Vt/vf With 30-day and 1-year Mortalitymentioning

confidence: 99%

Sustained Ventricular Tachycardia and Ventricular Fibrillation Complicating Non–ST-Segment–Elevation Acute Coronary Syndromes

et al. 2012

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Background-Ventricular arrhythmias remain a lethal complication of acute coronary syndromes (ACS). However, the incidence and prognosis of sustained ventricular tachycardia/ventricular fibrillation (VT/VF) in contemporary non-ST-segment-elevation (NSTE) ACS populations are not well described. Methods and Results-We examined the incidence of VT/VF and subsequent survival among 9211 patients enrolled in the Early Glycoprotein IIb/IIIa Inhibition in NSTE ACS (EARLY ACS) trial. The cumulative incidence of VT/VF was 1.5% (nϭ141); 0.6% (nϭ55) had VT/VF Յ48 hours after enrollment, and 0.9% (nϭ86) had VT/VF Ͼ48 hours after enrollment. Patients with VT/VF more frequently had prior heart failure, an ejection fraction Ͻ30%, and triple-vessel coronary artery disease. Predictors of sustained VT/VF were similar regardless of the timing of VT/VF (Յ48 versus Ͼ48 hours). Patients with VT/VF Յ48 hours after enrollment had higher 30-day mortality than those who did not have VT/VF Յ48 hours (13.0% versus 2.2%; adjusted odds ratio, 6.73; 95% confidence interval, 2.68 -16.9). The increased risk of death associated with VT/VF Յ48 hours persisted at 1 year.

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Early and Late Benefits of Prasugrel in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

Cited by 297 publications

References 22 publications

High On-Treatment Platelet Reactivity as a Risk Factor for Secondary Prevention After Coronary Stent Revascularization

High On-Treatment Platelet Reactivity as a Risk Factor for Secondary Prevention After Coronary Stent Revascularization

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Coronary Stenting

Sustained Ventricular Tachycardia and Ventricular Fibrillation Complicating Non–ST-Segment–Elevation Acute Coronary Syndromes

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