ticagrelor and Peripheral-Vascular-Diseases

Major adverse cardiac event (MACE) and bleeding risks following percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) are not well defined in individuals with heart failure (HF). We followed 1,145 individuals in the Pharmacogenomic Resource to improve Medication Effectiveness Genotype Guided Antiplatelet Therapy cohort for MACE and bleeding events following PCI for ACS. We constructed Cox proportional hazards models to compare MACE and bleeding in those with versus without HF, adjusting for sociodemographics, comorbidities, and medications. We also determined predictors of MACE and bleeding events in both groups. 370 (32%) individuals did and 775 (68%) did not have HF prior to PCI. Mean age was 61.7 ± 12.2 years, 31% were female, and 24% were African American. After a median follow-up of 0.78 years, individuals with HF had higher rates of MACE compared to those without HF (48 vs. 24 events per 100 person years) which remained significant after multivariable adjustment (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.00 to 1.72). Similarly, bleeding was higher in those with versus without HF (22 vs. 11 events per 100 person years), although this was no longer statistically significant after multivariable adjustment (HR 1.29, 95% CI 0.86 to 1.93). Diabetes and peripheral vascular disease were predictors of MACE, and end-stage renal disease was a predictor of bleeding among participants with HF. MACE risk is higher in individuals with versus without HF following PCI for ACS. However, the risk of bleeding, especially among those with end-stage renal disease , must be considered when determining post-PCI anticoagulant strategies.

Topics: Acute Coronary Syndrome; Aged; Angina, Unstable; Aspirin; Case-Control Studies; Clopidogrel; Diabetes Mellitus; Dual Anti-Platelet Therapy; Female; Heart Failure; Hemorrhage; Hospitalization; Humans; Ischemic Attack, Transient; Ischemic Stroke; Kidney Failure, Chronic; Male; Middle Aged; Mortality; Multivariate Analysis; Myocardial Infarction; Non-ST Elevated Myocardial Infarction; Percutaneous Coronary Intervention; Peripheral Vascular Diseases; Platelet Aggregation Inhibitors; Proportional Hazards Models; Risk Factors; ST Elevation Myocardial Infarction; Stroke Volume; Ticagrelor; Treatment Outcome

The recent publication of the PEGASUS and COMPASS studies could have a great influence on the clinical management of patients with stable ischemic heart disease. In the presence of possible eligibility for both approaches, a practical tool based on inclusion/exclusion criteria of the two studies could be useful for clinical decision of ideal treatment for suitable patients. We therefore report a simple nomogram helpful in identifying the treatment indicated on the base of patient's characteristics.

Topics: Aspirin; Cerebrovascular Disorders; Clinical Decision-Making; Clinical Protocols; Drug Administration Schedule; Drug Therapy, Combination; Factor Xa Inhibitors; Humans; Myocardial Infarction; Myocardial Ischemia; Peripheral Vascular Diseases; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Registries; Risk; Rivaroxaban; Ticagrelor

To investigate the safety and efficacy of ticagrelor in patients with critical limb ischemia (CLI) and high on-clopidogrel platelet reactivity (HCPR) undergoing complex, limb-salvage, peripheral endovascular procedures (PEP).. The study included consecutive patients with HCPR undergoing PEP for CLI. HCPR was defined as platelet reaction units (PRU) >234 as assessed by the VerifyNow P2Y12 assay. Patients with HCPR were prescribed ticagrelor, 180/90 mg twice daily, and aspirin, 100 mg daily, for 6 months and ticagrelor, 180/90 mg twice daily, thereafter. Primary safety outcome was total major bleeding, and primary efficacy outcome was the composite of cardiovascular death and major amputation. Secondary outcomes included the level of platelet inhibition achieved and target limb revascularization (TLR)-free survival rate.. In total, 37 CLI patients with 40 limbs were investigated. Mean follow-up period was 11.3 ± 5.0 months (range 6-21). The mean treated lesion length was 229.2 ± 71.4 mm in the femoropopliteal axis and 179.3 ± 83.9 mm in the infrapopliteal arteries. No major or minor bleeding was detected. There were four periprocedural minor adverse events (10.8%), and in two cases (5.6%) ticagrelor was discontinued. In all patients, ticagrelor achieved platelet inhibition lower than the cut-off value. Mean PRU during clopidogrel therapy was 308.4 ± 41.8 (range 257-422) versus 67.0 ± 52.8 (range 2-189) when switched to ticagrelor; p < 0.0001. Kaplan-Meier estimated primary efficacy outcome and TLR-free survival rates were 92.0 and 67.3% at 12 months, respectively.. In this series of CLI patients with HCPR undergoing complex PEP, initial experience with ticagrelor was proven safe and efficient because it resulted in sufficient platelet inhibition and satisfactory clinical results without major complications.

Topics: Adenosine; Adolescent; Adult; Aged; Aged, 80 and over; Aspirin; Clopidogrel; Endovascular Procedures; Female; Follow-Up Studies; Humans; Leg; Limb Salvage; Male; Middle Aged; Peripheral Vascular Diseases; Platelet Aggregation Inhibitors; Platelet Function Tests; Purinergic P2Y Receptor Antagonists; Retrospective Studies; Survival Rate; Ticagrelor; Ticlopidine; Treatment Outcome