Individualising dual antiplatelet therapy after percutaneous coronary intervention: the IDEAL-PCI registry

Abstract

ObjectiveTo evaluate the clinical utility of individualising dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in an all-comers population, including ST-elevation myocardial infarction (STEMI) patients.SettingTertiary care single centre registry.Participants1008 consecutive PCI patients with stent implantation, without exclusion criteria.InterventionPeri-interventional individualisation of DAPT, guided by multiple electrode aggregometry (MEA), to overcome high on-treatment platelet reactivity (HPR) to ADP-induced (≥50 U) and arachidonic acid (AA)-induced aggregation (>35 U).Outcome measuresThe primary efficacy end point was definite stent thrombosis (ST) at 30 days. The primary safety end point was thrombolysis in myocardial infarction (TIMI) major and minor bleeding. Secondary end points were probable ST, myocardial infarction, cardiovascular death and the combined end point: major cardiac adverse event (MACE).Results53% of patients presented with acute coronary syndrome (9% STEMI, 44% non-ST-elevation). HPR to ADP after 600 mg clopidogrel loading occurred in 30% of patients (73±19 U vs 28±11 U; p<0.001) and was treated by prasugrel or ticagrelor (73%), or clopidogrel (27%) reloading (22±12 U; p<0.001). HPR to ADP after prasugrel loading occurred in 2% of patients (82±26 U vs 19±10 U; p<0.001) and was treated with ticagrelor (34±15 U; p=0.02). HPR to AA occurred in 9% of patients with a significant higher proportion in patients with HPR to ADP (22% vs 4%, p<0.001) and was treated with aspirin reloading. Definite ST occurred in 0.09% of patients (n=1); probable ST, myocardial infarction, cardiovascular death and MACE occurred in 0.19% (n=2), 0.09% (n=1) and 1.8% (n=18) of patients. TIMI major and minor bleeding did not differ between patients without HPR and individualised patients (2.6% for both).ConclusionsIndividualisation of DAPT with MEA minimises early thrombotic events in an all-comers PCI population to an unreported degree without increasing bleeding. A randomised multicentre trial utilising MEA seems warranted.Trial registration numberhttp://www.clinicaltrials.gov; NCT01515345.

Assessment of platelet function in patients with stroke using multiple electrode platelet aggregometry: a prospective observational study

“…This recurrence has been associated with high on-treatment platelet reactivity (HPR), with up to more than 60% of subjects being reported to be resistant to antiplatelet therapy (aspirin or clopidogrel) [17, 18]. Although some studies showed a link between HPR and major adverse vascular events [19, 20], the use of platelet function analysis to detect and manage HPR continues to be debated. Most studies that investigated HPR were undertaken for patients already receiving antiplatelet therapy without assessing baseline platelet reactivity [19, 20], which may partly explain the conflicting results.…”

Platelet aggregation and risk of stent thrombosis or bleeding in interventionally treated diabetic patients with acute coronary syndrome

“…Different methods of laboratory assessment of platelet aggregation were used with the MEA Multiplate method repeatedly showing consistent results across several studies [20, 35, 57]. …”

Aspirin to Reduce the Risk of Thrombotic Events in Patients With End-Stage Renal Disease: Protocol for a Randomized Controlled Trial (Preprint)

“…The Multiplate will measure the platelet activity (defined as aggregation capability after activation with Adenosine diphosphate [ADP]) as an area under the curve reported in area units over time (AU*min). Platelet hyper-reactivity is defined based on the manufacturer's recommendations and published data, with a cut-off of 50 AU*min for ADP-induced aggregation (24).…”

“…After the study data is collected, the patient identification will be encoded, and only the investigator will have access to this information, in accordance with Good Clinical Practice and Helsinki declaration of patient confidence (24). The collected data will be entered electronically in a Research Electronic Data Capture management system (REDCap).…”