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Acute Coronary Syndromes: Precision Treatment

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 January 2021) | Viewed by 22171

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Dr. Eliano Navarese

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1. Department of Cardiology and Internal Medicine, Antoni Jurasz University Hospital, Nicolaus Copernicus University, Bydgoszcz, Poland
2. Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
Interests: interventional and pharmacological treatments of high risk patients; acute coronary syndrome; personalized medicine; clinical trials; evidence-based medicine

Special Issue Information

Dear Colleagues,

Acute coronary syndrome (ACS) remains a leading cause of mortality worldwide. Substantial advancements have been made in the field with the availability of antithrombotic and anticoagulant regimens that have significantly reduced the rate of ischemic events at the expense of increased bleeding risk. In concert with the pharmacological strategies, in the recent years there was a progressive refinement of the drug-eluting stent technology during the percutaneous coronary intervention (PCI) for ACS. Following the index PCI the universal recommendation of 12-month duration of dual antiplatelet therapy (DAPT) has been broadened in the international guidelines by the addition of shorter or longer DAPT regimens based on the higher ischemic and bleeding patient profile. The real word scenario of an ACS is characterized by the growing complexity of the treated patients who are often at advanced age and at risk of both ischemic and bleeding complications. Balancing thrombotic and bleeding risk is therefore pivotal in these high-risk subjects.

Precision medicine studies are investigations that adopt diagnostic and therapeutic algorithms calibrated on the patient individual risk. With this background, Precision Medicine studies are advocated in the scientific community with the goal to improve risk stratification and optimize the care of the ACS patients.

Dr. Eliano Navarese
Guest Editor

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Keywords

Acute coronary syndrome
Atherosclerosis
Myocardial infarction
Pharmacology
Hypertension
Cardiovascular medicine
Clinical cardiology

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Published Papers (7 papers)

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Research

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13 pages, 2737 KiB

Open AccessArticle

Five-Year Comparative Efficacy of Everolimus-Eluting vs. Resolute Zotarolimus-Eluting Stents in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

by Endrin Koni, Wojciech Wanha, Jakub Ratajczak, Zhongheng Zhang, Przemysław Podhajski, Rita L. Musci, Giuseppe M. Sangiorgi, Maciej Kaźmierski, Antonio Buffon, Jacek Kubica, Wojciech Wojakowski and Eliano P. Navarese

J. Clin. Med. 2021, 10(6), 1278; https://doi.org/10.3390/jcm10061278 - 19 Mar 2021

Cited by 5 | Viewed by 3113

Abstract

Among drug-eluting stents (DESs), the durable polymer everolimus-eluting stent (EES) and resolute zotarolimus-eluting stent (R-ZES) are widely used in clinical practice and have contributed to improve the outcomes of patients undergoing percutaneous coronary intervention (PCI). Few studies addressed their long-term comparative performance in patients with acute coronary syndrome (ACS). We aimed to investigate the 5 year comparative efficacy of EES and R-ZES in ACS. We queried ACTION-ACS, a large-scale database of ACS patients undergoing PCI. The treatment groups were analyzed using propensity score matching. The primary endpoint was a composite of mortality, myocardial infarction (MI), stroke, repeat PCI, and definite or probable stent thrombosis, which was addressed at the five-year follow-up. A total of 3497 matched patients were analyzed. Compared with R-ZES, a significant reduction in the primary endpoint at 5 years was observed in patients treated with EES (hazard ratio (HR) [95%CI] = 0.62 [0.54–0.71], p < 0.001). By landmark analysis, differences between the two devices emerged after the first year and were maintained thereafter. The individual endpoints of mortality (HR [95%CI] = 0.70 [0.58–0.84], p < 0.01), MI (HR [95%CI] = 0.55 [0.42–0.74], p < 0.001), and repeat PCI (HR [95%CI] = 0.65 [0.53–0.73], p < 0.001) were all significantly lower in the EES-treated patients. Stroke risk did not differ between EES and R-ZES. In ACS, a greater long-term clinical efficacy with EES vs. R-ZES was observed. This difference became significant after the first year of the ACS episode and persisted thereafter. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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12 pages, 1295 KiB

Open AccessArticle

Temporal Trends of Bleeding Episodes during Half- vs. Standard-Dose Ticagrelor in Acute Coronary Syndrome Patients with Low Platelet Reactivity: A Randomized BLEEDING-ACS Trial

by Laeun Kim, Jeong Cheon Choe, Jin Hee Ahn, Hye Won Lee, Jun-Hyok Oh, Jung Hyun Choi, Han Cheol Lee, Kwang Soo Cha, Taek Jong Hong, Young-Hoon Jeong and Jin Sup Park

J. Clin. Med. 2021, 10(6), 1159; https://doi.org/10.3390/jcm10061159 - 10 Mar 2021

Cited by 4 | Viewed by 2701

Abstract

To assess the temporal trends of bleeding episodes during half- vs. standard-dose ticagrelor in acute coronary syndrome (ACS) patients with low platelet reactivity (LPR) during standard-dose ticagrelor (90 mg bid). ACS Patients with LPR (<85 P2Y₁₂ reaction units) (n = 122) were randomly assigned to receive either half-dose (45 mg bid) or standard-dose ticagrelor (90 mg bid). The primary endpoint was incidence of Bleeding Academic Research Consortium (BARC) bleeding at 1 week, 1, 3 and 6 months. Dyspnea and ischemic events were also evaluated. Bleeding episodes were most commonly observed at 1 month and then decreased over time. Half-dose ticagrelor did not reduce any BARC bleeding (odds ratio [OR] 0.900, 95% confidence interval [CI] 0.563–1.440, p = 0.661). However, serious bleeding (BARC type ≥2) occurred less often in half-dose ticagrelor (OR 0.284, 95% CI 0.088–0.921, p = 0.036). The rate of moderate-to-severe dyspnea was highest at 1 month, then decreased over time. Half-dose ticagrelor did not decrease moderate-to-severe dyspnea (Borg scale ≥ 3) (OR 1.066, 95% CI 0.322–3.530, p = 0.916). The risk of ischemic events was also similar between the groups. In conclusions, compared with standard-dose ticagrelor, half-dose ticagrelor reduced serious bleeding events during early period of dual-antiplatelet therapy in ACS patients with LPR; however, the risk of any bleeding events and dyspnea did not differ according to ticagrelor dose. Clinical registration: KCT0004640. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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12 pages, 2358 KiB

Open AccessArticle

Therapy Discontinuation after Myocardial Infarction

by Łukasz Pietrzykowski, Michał Kasprzak, Piotr Michalski, Agata Kosobucka, Tomasz Fabiszak and Aldona Kubica

J. Clin. Med. 2020, 9(12), 4109; https://doi.org/10.3390/jcm9124109 - 19 Dec 2020

Cited by 6 | Viewed by 2662

Abstract

The discontinuation of recommended therapy after myocardial infarction predisposes patients to serious thrombotic complications. The aim of this study was a comprehensive analysis of permanent as well as short- and long-term discontinuation of pharmacotherapy, taking into consideration the basic groups of medications and nonadherence determinants in a one-year follow-up in post-myocardial infarction (MI) patients. Material and methods: The study was a single center cohort clinical trial with a one-year follow-up including 225 patients (73.3% men, 26.7% women) aged 62.9 ± 11.9 years. In eight cases (3.6%), the follow-up duration was less than one year due to premature death. The following factors were analyzed: lack of post-discharge therapy initiation; short-term therapy discontinuation (<30 days); long-term therapy discontinuation (≥30 days); and permanent cessation of therapy. The analysis of therapy discontinuation was performed based on prescription filling data. Results: Occupational activity (Odds Ratio (OR) 5.15; 95% Confidence interval (CI) 1.42–18.65; p = 0.013) and prior MI (OR 5.02; 95% CI 1.45–16.89; p = 0.009) were found to be independent predictors of a lack of post-discharge therapy initiation with P2Y₁₂ receptor inhibitors. We found no independent predictors of lack of post-discharge therapy initiation with other medications, whether analyzed separately or together. Age above 65 years (Hazard Ratio (HR)—1.59; 95% CI 1.15–2.19; p = 0.0049) and prior revascularization (HR—1.44; 95% CI 1.04–2.19; p = 0.0273) were identified as independent predictors of therapy discontinuation. Multilogistic regression analysis showed no independent predictors of the cessation of any of the medications as well as the permanent or temporary simultaneous discontinuation of all medications. Conclusions: The vast majority of post-MI patients discontinue, either temporarily or permanently, one of the essential medications within one year following myocardial infarction. The most likely medication class to be discontinued are statins. Older age and prior cardiac revascularization are independent determinants of therapy discontinuation. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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13 pages, 1208 KiB

Open AccessArticle

Ischemic and Bleeding Events Associated with Thrombocytopenia and Thrombocytosis after Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

by Ji Woong Roh, Sungmin Lim, Youngdeok Hwang, Kwan Yong Lee, Eun Ho Choo, Ik Jun Choi, Byung-Hee Hwang, Chan Joon Kim, Mahn-Won Park, Dong-Bin Kim, Jong-Min Lee, Chul Soo Park, Hee-Yeol Kim, Ki-Dong Yoo, Doo Soo Jeon, Ho Joong Youn, Wook Sung Chung, Min Chul Kim, Myung Ho Jeong, Youngkeun Ahn and Kiyuk Chang Show full author list Hide full author list

J. Clin. Med. 2020, 9(10), 3370; https://doi.org/10.3390/jcm9103370 - 21 Oct 2020

Cited by 11 | Viewed by 2647

Abstract

The early and late ischemic and bleeding clinical outcomes according to baseline platelet count after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) remain unclear. Overall, 10,667 patients from the Cardiovascular Risk and identification of potential high-risk population in AMI (COREA-AMI) I and II registries were classified according to the following universal criteria on baseline platelet counts: (1) moderate to severe thrombocytopenia (platelet < 100 K/μL, n = 101), (2) mild thrombocytopenia (platelet = 100~149 K/μL, n = 631), (3) normal reference (platelet = 150~450 K/μL, n = 9832), and (4) thrombocytosis (platelet > 450 K/μL, n = 103). The primary endpoint was the occurrence of major adverse cardiovascular events (MACE). The secondary outcome was Bleeding Academic Research Consortium (BARC) 2, 3, and 5 bleeding. After adjusting for confounders, the moderate to severe thrombocytopenia (HR, 2.03; 95% CI, 1.49–2.78); p < 0.001), mild thrombocytopenia (HR, 1.15; 95% CI, 1.01–1.34; p = 0.045), and thrombocytosis groups (HR, 1.47; 95% CI, 1.07–2.03; p = 0.019) showed higher 5-year MACE rates than the normal reference. In BARC 2, 3, and 5 bleeding outcomes, the bleedings rates were higher than the normal range in the moderate to severe thrombocytopenia (HR, 2.18; 95% CI, 1.36–3.49; p = 0.001) and mild thrombocytopenia (HR, 1.41; 95% CI, 1.12–1.78; p = 0.004) groups. Patients with AMI had higher 5-year MACE rates after PCI if they had lower- or higher-than-normal platelet counts. Thrombocytopenia revealed higher early and late bleeding rates whereas thrombocytosis showed long-term bleeding trends, although these trends were not statistically significant. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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9 pages, 415 KiB

Open AccessArticle

Ticagrelor Versus Clopidogrel in Older Patients with NSTE-ACS Using Oral Anticoagulation: A Sub-Analysis of the POPular Age Trial

by Marieke E. Gimbel, Anne H. Tavenier, Wilbert Bor, Renicus S. Hermanides, Evelyn de Vrey, Ton Heestermans, Melvyn Tjon Joe Gin, Reinier Waalewijn, Sjoerd Hofma, Frank den Hartog, Wouter Jukema, Clemens von Birgelen, Michiel Voskuil, Johannes Kelder, Vera Deneer and Jurriën M. ten Berg

J. Clin. Med. 2020, 9(10), 3249; https://doi.org/10.3390/jcm9103249 - 12 Oct 2020

Cited by 7 | Viewed by 3216

Abstract

There are no randomised data on which antiplatelet agent to use in elderly patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and an indication for oral anticoagulation (OAC). The randomised POPular Age trial, in patients of 70 years or older with NSTE-ACS, showed a reduction in bleeding without increasing thrombotic events in patients using clopidogrel as compared to ticagrelor. In this sub-analysis of the POPular AGE trial, we compare clopidogrel with ticagrelor in patients with a need for oral anticoagulation. The follow-up duration was one year. The primary bleeding outcome was Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding. The primary thrombotic outcome consisted of cardiovascular death, myocardial infarction and stroke. The primary net clinical benefit outcome was a composite of all-cause death, myocardial infarction, stroke, and PLATO major and minor bleeding. A total of 184/1011 (18.2%) patients on OAC were included in this subanalysis; 83 were randomized to clopidogrel and 101 to ticagrelor. The primary bleeding outcome was lower in the clopidogrel group (17/83, 20.9%) compared to the ticagrelor group (33/101, 33.5%; p = 0.051), as was the thrombotic outcome (7/83, 8.4% vs. 19/101, 19.2%; p = 0.035) and the primary net clinical benefit outcome (23/83, 27.7% vs. 49/101, 48.5%; p = 0.003). In this subgroup of patients using OAC, clopidogrel reduced PLATO major and minor bleeding compared to ticagrelor without increasing thrombotic risk. This analysis therefore suggests that, in line with the POPular Age trial, clopidogrel is a better option than ticagrelor in NSTE-ACS patients ≥70 years using OAC. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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Review

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8 pages, 520 KiB

Open AccessReview

Precision Treatment in ACS–Role of Assessing Fibrinolysis

by Ying X. Gue, Young-Hoon Jeong, Mohamed Farag, Nikolaos Spinthakis and Diana A. Gorog

J. Clin. Med. 2021, 10(5), 929; https://doi.org/10.3390/jcm10050929 - 1 Mar 2021

Cited by 2 | Viewed by 4712

Abstract

Despite advancements in pharmacotherapy and interventional strategies, patients with acute coronary syndrome (ACS) remain at risk of recurrent thrombotic events. In addition to an enhanced tendency to thrombus formation, impairment in the ability to naturally dissolve or lyse a developing thrombus, namely impaired endogenous fibrinolysis, is responsible for a major part of this residual risk regardless of optimal antiplatelet medication. Global assessment of endogenous fibrinolysis, including a point-of-care assay, can identify patients with ACS at persistent high cardiovascular risk and might play an important role in allowing the personalisation of potent antithrombotic therapy to enhance fibrinolytic status, providing precision treatment of ACS to improve long-term outcome. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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Other

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9 pages, 474 KiB

Open AccessViewpoint

Precision Phenomapping of Acute Coronary Syndromes to Improve Patient Outcomes

by Felicita Andreotti, Adelaide Iervolino, Eliano Pio Navarese, Aldo Pietro Maggioni, Filippo Crea and Giovanni Scambia

J. Clin. Med. 2021, 10(8), 1755; https://doi.org/10.3390/jcm10081755 - 18 Apr 2021

Cited by 1 | Viewed by 2205

Abstract

Acute coronary syndromes (ACS) are a global leading cause of death. These syndromes show heterogeneity in presentation, mechanisms, outcomes and responses to treatment. Precision medicine aims to identify and synthesize unique features in individuals, translating the acquired data into improved personalised interventions. Current precision treatments of ACS include immediate coronary revascularisation driven by ECG ST-segment elevation, early coronary angiography based on elevated blood cardiac troponins in patients without ST-segment elevation, and duration of intensified antithrombotic therapy according to bleeding risk scores. Phenotypically stratified analyses of multi-omic datasets are urgently needed to further refine and couple the diagnosis and treatment of these potentially life-threatening conditions. We provide definitions, examples and possible ways to advance precision treatments of ACS. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Precision Treatment)

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