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A pharmacodynamic comparison of 5 anti-platelet protocols in patients with ST-elevation myocardial infarction undergoing primary PCI.

Koul S, Andell P, Martinsson A, Smith JG, Scherstén F, Harnek J, Götberg M, Norström E, Björnsson S, Erlinge D - BMC Cardiovasc Disord (2014)

Bottom Line: Only 32% of patients receiving clopidogrel only were responders the day after PCI.Switching from an upstream bolus dose of clopidogrel to prasugrel at the time of PCI, appeared as a safe and feasible option with no tendency for overshoot or attenuation of platelet inhibition.Pre-hospital administration of ticagrelor was associated with a 50% good responder rate at completion of PCI.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Lund University, Skåne University Hospital Lund, SE 221 85, Lund, Sweden. sasha.koul@med.lu.se.

ABSTRACT

Background: Despite advances in anti-platelet treatments, there still exists an early increase in both ischemic as well as bleeding events following primary PCI in patients with ST-elevation myocardial infarction (STEMI). Platelet inhibition data of different anti-platelet treatments in the acute phase of a myocardial infarction might offer some insight into these problems. The aim of this study was to evaluate the pharmacodynamic profile of 5 different anti-platelet treatments in the acute phase of STEMI in patients undergoing primary PCI.

Methods: A total of 223 STEMI patients undergoing primary PCI were prospectively included. Patients received either pre-hospital clopidogrel only, pre-hospital clopidogrel followed by prasugrel switch in the cath lab, prasugrel treatment only, pre-hospital clopidogrel followed by ticagrelor switch in the cath lab or pre-hospital ticagrelor only. Platelet reactivity was measured serially using vasodilator-stimulated phosphoprotein (VASP).

Results: Patients receiving pre-hospital clopidogrel followed by prasugrel switch showed similar platelet inhibition data as patients receiving prasugrel only, with more than 90% being good responders the day after PCI. Average time from prasugrel administration to a VASP value of <50% was 1.5 hours. In patients receiving pre-hospital ticagrelor, 50% were good responders at completion of PCI and average time to a VASP-value of <50% was 2.3 hours. Only 32% of patients receiving clopidogrel only were responders the day after PCI.

Conclusions: Switching from an upstream bolus dose of clopidogrel to prasugrel at the time of PCI, appeared as a safe and feasible option with no tendency for overshoot or attenuation of platelet inhibition. Pre-hospital administration of ticagrelor was associated with a 50% good responder rate at completion of PCI.

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Related in: MedlinePlus

Clinical protocol. Flow-chart describing the 5 patient cohorts in the study and timings of blood sampling.
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Fig1: Clinical protocol. Flow-chart describing the 5 patient cohorts in the study and timings of blood sampling.

Mentions: Patients undergoing PCI for STEMI at Skåne University Hospital in Lund were prospectively included in the Lund Platelet Registry from October 2009 to October 2012 (total n = 223). All STEMI patients were eligible for inclusion. However if the patients had not received a P2Y12-inhibitor or primary PCI was not performed, they were excluded. Aspirin treatment was given as standard treatment unless contraindicated in the individual patient. Bivalirudin was used as first-line anti-thrombotic adjuvant therapy during PCI. Usage of GPIIb/IIIa-inhibitors were used as bail-out option at the physician’s discretion (Table 1). Platelet reactivity was measured serially using a flow cytometric assay for the vasodilator-stimulated phosphoprotein (VASP) at three time-points: a) After performed angiography prior to PCI (pre-PCI VASP) b) after completed PCI procedure (post-PCI VASP) and c) the following morning after PCI (day after VASP). A total of 5 different cohorts were included according to their P2Y12-inhibition (Figure 1). 1) At the time of initiation of the registry all patients were treated with upstream clopidogrel only (upstream clopidogrel group, n = 75).Table 1


A pharmacodynamic comparison of 5 anti-platelet protocols in patients with ST-elevation myocardial infarction undergoing primary PCI.

Koul S, Andell P, Martinsson A, Smith JG, Scherstén F, Harnek J, Götberg M, Norström E, Björnsson S, Erlinge D - BMC Cardiovasc Disord (2014)

Clinical protocol. Flow-chart describing the 5 patient cohorts in the study and timings of blood sampling.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4274705&req=5

Fig1: Clinical protocol. Flow-chart describing the 5 patient cohorts in the study and timings of blood sampling.
Mentions: Patients undergoing PCI for STEMI at Skåne University Hospital in Lund were prospectively included in the Lund Platelet Registry from October 2009 to October 2012 (total n = 223). All STEMI patients were eligible for inclusion. However if the patients had not received a P2Y12-inhibitor or primary PCI was not performed, they were excluded. Aspirin treatment was given as standard treatment unless contraindicated in the individual patient. Bivalirudin was used as first-line anti-thrombotic adjuvant therapy during PCI. Usage of GPIIb/IIIa-inhibitors were used as bail-out option at the physician’s discretion (Table 1). Platelet reactivity was measured serially using a flow cytometric assay for the vasodilator-stimulated phosphoprotein (VASP) at three time-points: a) After performed angiography prior to PCI (pre-PCI VASP) b) after completed PCI procedure (post-PCI VASP) and c) the following morning after PCI (day after VASP). A total of 5 different cohorts were included according to their P2Y12-inhibition (Figure 1). 1) At the time of initiation of the registry all patients were treated with upstream clopidogrel only (upstream clopidogrel group, n = 75).Table 1

Bottom Line: Only 32% of patients receiving clopidogrel only were responders the day after PCI.Switching from an upstream bolus dose of clopidogrel to prasugrel at the time of PCI, appeared as a safe and feasible option with no tendency for overshoot or attenuation of platelet inhibition.Pre-hospital administration of ticagrelor was associated with a 50% good responder rate at completion of PCI.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Lund University, Skåne University Hospital Lund, SE 221 85, Lund, Sweden. sasha.koul@med.lu.se.

ABSTRACT

Background: Despite advances in anti-platelet treatments, there still exists an early increase in both ischemic as well as bleeding events following primary PCI in patients with ST-elevation myocardial infarction (STEMI). Platelet inhibition data of different anti-platelet treatments in the acute phase of a myocardial infarction might offer some insight into these problems. The aim of this study was to evaluate the pharmacodynamic profile of 5 different anti-platelet treatments in the acute phase of STEMI in patients undergoing primary PCI.

Methods: A total of 223 STEMI patients undergoing primary PCI were prospectively included. Patients received either pre-hospital clopidogrel only, pre-hospital clopidogrel followed by prasugrel switch in the cath lab, prasugrel treatment only, pre-hospital clopidogrel followed by ticagrelor switch in the cath lab or pre-hospital ticagrelor only. Platelet reactivity was measured serially using vasodilator-stimulated phosphoprotein (VASP).

Results: Patients receiving pre-hospital clopidogrel followed by prasugrel switch showed similar platelet inhibition data as patients receiving prasugrel only, with more than 90% being good responders the day after PCI. Average time from prasugrel administration to a VASP value of <50% was 1.5 hours. In patients receiving pre-hospital ticagrelor, 50% were good responders at completion of PCI and average time to a VASP-value of <50% was 2.3 hours. Only 32% of patients receiving clopidogrel only were responders the day after PCI.

Conclusions: Switching from an upstream bolus dose of clopidogrel to prasugrel at the time of PCI, appeared as a safe and feasible option with no tendency for overshoot or attenuation of platelet inhibition. Pre-hospital administration of ticagrelor was associated with a 50% good responder rate at completion of PCI.

Show MeSH
Related in: MedlinePlus