Effect of prasugrel versus clopidogrel on outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention without stent implantation: A TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with prasugrel (TRITON)–Thrombolysis in Myocardial Infarction (TIMI) 38 Substudy

Pride, Yuri B.; Wiviott, Stephen D.; Buros, Jacqueline L.; Zorkun, Cafer; Tariq, Muhammad Umer; Antman, Elliott M.; Braunwald, Eugene; Gibson, C. Michael

doi:10.1016/j.ahj.2009.06.021

Cited by 34 publications

(24 citation statements)

References 14 publications

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“…For patients with a high risk, who develop an unstable cardiac condition, this initial admission delays a potentially lifesaving treatment and prolongs the admission. It has been shown that 63% of patients with NSTEMI have significant flow limiting coronary disease and that coronary occlusion may persist for days after symptom onset [49,50]. With the recent advances in STEMI care and associated improved outcome, the mortality in patients with NSTEMI is now comparable to and may even exceed that of patients with STEMI [51,52].…”

Section: Prehospital Biomarker Measurementmentioning

confidence: 88%

Prehospital diagnosis of patients with acute myocardial infarction

et al. 2016

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Primary percutaneous intervention (PPCI) is the preferred treatment in patients with ST elevation myocardial infarction (STEMI) if this can be performed in a timely manner. The 2012 ESC Guidelines on management of AMI in patients presenting with ST-segment elevation advice that PPCI should be performed within 120 min of first medical contact. Prehospital diagnosis of patients with STEMI is performed to save time and make PPCI available to the majority of patients. Although diagnosing patients with STEMI is usually easy, there are important pitfalls and patients with STEMI are missed on occasion. In addition, it is well know that patients without ST elevation may also have a high-risk cardiac condition. The 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation stress the importance of urgent CAG in patients with high-risk non ST-segment elevation myocardial infarction (NSTEMI). Unfortunately, these patients are difficult to diagnose in the acute phase and important time may be spend establishing the correct diagnosis. Prehospital biomarker measurement has emerged as a method to gain important additional information. We review the evidence on prehospital diagnosis of patients with STEMI and, In addition, we present the current knowledge on the new diagnostic methods that could have a future role in prehospital rule-in and rule-out of cardiac disease.

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Section: Prehospital Biomarker Measurementmentioning

confidence: 88%

Prehospital diagnosis of patients with acute myocardial infarction

et al. 2016

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“…The first relevant data in the study is the percentage of recurrence in patients treated with clopidogrel, which is of 20.1%, as confirmed by other studies [10,20]. This may mean a failed therapeutic effectiveness of the drug and it is therefore important, in the clinical practice, to discover the possible generating factors.…”

Section: Discussionmentioning

confidence: 55%

Clinical Analysis of the Pharmacological Interactions of Clopidogrel and Gender Differences: A Case-Control Study

Stefano¹,

Casellato²,

Bianchini³

et al. 2012

IJCM

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Background: Clopidogrel is a prodrug metabolized by cytochrome P450-2C19. Drugs inhibiting this enzyme might reduce its antiplatelet activity. In order to reduce gastrointestinal bleedings, proton-pump inhibitors are usually prescribed in association with clopidogrel. The study aims at assessing the clinical importance of interactions between clopidogrel and inhibitors of CYP2C19. It also aims to evaluate any possible factors that may reduce the therapeutic efficacy of the drug. Particular attention was devoted to possible gender differences in responsiveness to treatment with clopidogrel or clopidogrel plus proton-pump inhibitors. This analysis is a retrospective case-control observational study carried out by the University Hospital of Ferrara. Methods: Subjects were patients who had received clopidogrel from 01-01-2008 to 31-12-2008. For them, we analysed hospital admissions and data of drug prescriptions relative to dispensing of drugs cytochrome P-450-2C19 inhibitors. Patients were subdivided into case and control groups based on the occurrence or not of cardiovascular or cerebrovascular secondary events during therapy with clopidogrel. Results: The study focused on 781 patients, 20.1% of which (n.157) experienced secondary effects. The mean age is 70 years old. Men (67% of the analyzed population) experienced secondary events more than women (OR 1.54; CI 95% 1.04 -2.28; p < 0.03). 70% of patients took PPIs and we noticed that the risk of secondary events increased by 2.2% with respect to the remaining patients (20.77% vs 18.57%; OR 1.15; CI 0.78 -1.70; p = NS). Among PPIs, lansoprazole is the most used. For this subgroup the risk is 5.2% higher (risk in those exposed of 23.75% vs 18.57% in those not exposed; or 1.37, 95% CI 0.92 -2.03; p = NS). The interaction with PPIs is particularly interesting only among women, with a risk 6.3% higher (17.46% exposed, 11.11% non exposed). The risk remains the same among men. Conclusions: Analyzed data show an increase in cardiovascular or cerebral secondary events for patients exposed to PPIs. It also demonstrated the existence of differrent gender in therapeutic response to clopidogrel.

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“…Major bleed (4) Single antiplatelet therapy at end of 12 mo (2). In addition to repeat ACS (2), patients could also have a major bleed (4).…”

Section: Model Structurementioning

confidence: 99%

“…[1][2][3] The CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial showed that clopidogrel reduced adverse cardiovascular events when combined with ASA for 12 months after ACS. 1 However, the individual response to clopidogrel is limited by various factors.…”

mentioning

confidence: 99%

Cost-effectiveness of clopidogrel, prasugrel and ticagrelor for dual antiplatelet therapy after acute coronary syndrome: a decision-analytic model

Abdel‐Qadir¹,

Roifman²,

Wijeysundera³

2015

CMAJ Open

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Background: The use of prasugrel or ticagrelor as part of dual antiplatelet therapy with acetylsalicylic acid after acute coronary syndrome (ACS) improves clinical outcomes relative to clopidogrel. The relative cost-effectiveness of these agents are unknown. We conducted an economic analysis evaluating 12 months of treatment with clopidogrel, prasugrel or ticagrelor after ACS. Methods:We developed a fully probabilistic Markov cohort decision-analytic model using a lifetime horizon, from the perspective of the Ontario Ministry of Health and Long-Term Care. The model incorporated risks of death, recurrent ACS, heart failure, major bleeding and other adverse effects of treatment. Data on probabilities and utilities were obtained from the published literature where available. The primary outcome was quality-adjusted life-years (QALYs).Results: Treatment with clopidogrel was associated with the lowest effectiveness (7.41 QALYs, 95% confidence interval [CI] 1.05-14.79) and the lowest cost ($39 601, 95% CI $8434-$111 186). Ticagrelor treatment had an effectiveness of 7.50 QALYs (95% CI 1.13-14.84) at a cost of $40 649 (95% CI $9327-$111 881). The incremental cost-effectiveness ratio (ICER) for ticagrelor relative to clopidogrel was $12 205 per QALY gained. Prasugrel had an ICER of $57 630 per QALY gained relative to clopidogrel. Ticagrelor was the preferred option in 90% of simulations at a willingness-to-pay threshold of $50 000 per QALY gained. Interpretation:Ticagrelor was the most cost-effective agent when used as part of dual antiplatelet therapy after ACS. This conclusion was robust to wide variations in model parameters. AbstractResearch CMAJ OPEN CMAJ OPEN, 3(4) E439

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Cited by 34 publications

References 14 publications

Prehospital diagnosis of patients with acute myocardial infarction

Prehospital diagnosis of patients with acute myocardial infarction

Clinical Analysis of the Pharmacological Interactions of Clopidogrel and Gender Differences: A Case-Control Study

Cost-effectiveness of clopidogrel, prasugrel and ticagrelor for dual antiplatelet therapy after acute coronary syndrome: a decision-analytic model

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