Ticagrelor vs. clopidogrel in patients with acute coronary syndromes and diabetes: a substudy from the PLATelet inhibition and patient Outcomes (PLATO) trial

James, Stefan; Angiolillo, Dominick J.; Cornel, Jan H.; Erlinge, David; Husted, Steen; Kontny, Frederic; Maya, Juan; Nicolau, José Carlos; Špinar, Jindřich; Storey, Robert F.; Stevens, Susanna R.; Wallentin, Lars

doi:10.1093/eurheartj/ehq325

Cited by 389 publications

(269 citation statements)

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“…In the setting of PCI, stent thrombosis is a catastrophic complication leading to death or myocardial infarction and several studies report a strong association with the presence of diabetes 19. Subgroup analyses in both The Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel‐Thrombolysis in Myocardial Infarction 38 (TRITON‐TIMI 38) 20 and the PLATelet inhibition and patient Outcomes (PLATO) trial 21 confirmed the beneficial role of more powerful antiplatelet agents when compared with clopidogrel in the diabetic arm but even so, this population had ischemic outcomes that were approximately 20% higher than in the non‐diabetic population. Dual antiplatelet therapy is not currently recommended in primary prevention in patients with diabetes and, in secondary prevention, it is only recommended for 12 months 22.…”

Section: Discussionmentioning

confidence: 99%

Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus

Noman

Balasubramaniam

Alhous

et al. 2016

Cathet Cardio Intervent

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ObjectivesTo assess the mortality in patients with diabetes mellitus (DM) following percutaneous coronary intervention (PCI) according to their insulin requirement and PCI setting (elective, urgent, and emergency).BackgroundDM is a major risk factor to develop coronary artery disease (CAD). It is unclear if meticulous glycemic control and aggressive risk factor management in patients with DM has improved outcomes following PCI.MethodsRetrospective analysis of prospectively collected data on 9,224 patients treated with PCI at a regional tertiary center between 2008 and 2011.ResultsAbout 7,652 patients were nondiabetics (non‐DM), 1,116 had non‐insulin treated diabetes mellitus (NITDM) and 456 had ITDM. Multi‐vessel coronary artery disease, renal impairment and non‐coronary vascular disease were more prevalent in DM patients. Overall 30‐day mortality rate was 2.4%. In a logistic regression model, the adjusted odds ratios (95% confidence intervals [CI]) for 30‐day mortality were 1.28 (0.81–2.03, P = 0.34) in NITDM and 2.82 (1.61–4.94, P < 0.001) in ITDM compared with non‐DM. During a median follow‐up period of 641 days, longer‐term post‐30 day mortality rate was 5.3%. In the Cox's proportional hazard model, the hazard ratios (95% CI) for longer‐term mortality were 1.15 (0.88–1.49, P = 0.31) in NITDM and 1.88 (1.38–2.55, P < 0.001) in ITDM compared with non‐DM group. Similar result was observed in all three different PCI settings.ConclusionIn the modern era of aggressive cardiovascular risk factor control in diabetes, this study reveals higher mortality only in insulin‐treated diabetic patients following PCI for stable coronary artery disease and acute coronary syndrome. Importantly, diabetic patients with good risk factor control and managed on diet or oral hypoglycemics have similar outcomes to the non‐diabetic population. © 2016 The Authors Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

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Section: Discussionmentioning

confidence: 99%

Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus

Noman

Balasubramaniam

Alhous

et al. 2016

Cathet Cardio Intervent

View full text Add to dashboard Cite

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“…In routine clinical practice, physician decisions about antiplatelet therapy choice may be based on several factors unique to the individual patient, including predicted risk of recurrent events, predicted safety, and cost of treatment. Although patients with diabetes mellitus have been shown to benefit from higher‐potency P2Y 12 inhibitor therapy,26, 27 diabetes mellitus was not a significant factor associated with P2Y 12 inhibitor intensification. Bleeding before the recurrent ischemic event was rare, and its rarity likely explains its lack of statistically significant association with P2Y 12 inhibitor intensification.…”

Section: Discussionmentioning

confidence: 86%

Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into Contemporary Practice From the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) Study

Kaltenbach

Peterson

Akhter

et al. 2018

JAHA

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BackgroundGuidelines recommend P2Y12 inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y12 inhibitor type among patients with recurrent ischemic events in the first year after MI.Methods and ResultsThe TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y12 inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y12 inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th–75th percentiles, 55–287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel‐treated patients led to P2Y12 inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y12 inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y12 inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification.ConclusionsFew patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y12 inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503.

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“…23 In patients with DM, the reduction in major adverse cardiovascular events was similar to the overall population, with a 2.1% absolute risk reduction. 52 There was also a trend toward a reduction in stent thrombosis among diabetic patients.…”

Section: Antiplatelet Therapymentioning

confidence: 95%

Percutaneous Coronary Intervention in Patients With Diabetes

Armstrong

Waltenberger

Rogers

2014

J Diabetes Sci Technol

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Over 170 million people worldwide have diabetes mellitus (DM), with an increasing proportion of these patients diagnosed in the developing world.1 Despite medical advances in prevention of coronary artery disease (CAD), the rising prevalence of DM threatens to increase the global burden of cardiovascular disease in the next 2 decades.2 Currently, patients with DM compose 25% to 30% of all patients undergoing coronary artery revascularization.3 Up to 60% of patients presenting with acute myocardial infarction may also have previously unrecognized diabetes. [4][5][6] The increasing recognition that DM is associated with adverse outcomes after coronary revascularization has led to the development of newer stent technologies and pharmacotherapies that may be differentially utilized in diabetic patients.This article reviews revascularization strategies, the current use of percutaneous coronary intervention (PCI), new developments in stent technology, and the importance of medical therapy after PCI among patients with DM. Timing of Revascularization and Revascularization StrategyPatients with DM have more diffuse and complex CAD than nondiabetic patients. 7 Revascularization of high-risk anatomy including proximal LAD stenosis is also associated with mortality benefit among patients with DM.8 Some have therefore advocated performing revascularization in diabetic patients regardless of symptoms. Balanced against these benefits is the observation that patients with DM who undergo revascularization experience less improvement in anginal symptoms compared to nondiabetics. 9 The BARI 2D trial was the first large randomized trial to enroll exclusively diabetic patients with CAD and stable angina. 10 This study demonstrated that an initial revascularization strategy plus optimal medical therapy yielded outcomes similar to optimal medical therapy with deferral of revascularization. Even with a deferred strategy, however, 38% of patients required revascularization during a 5-year follow-up period. 11Importantly, patients with left main coronary artery stenosis ≥ 50% or uncontrolled angina were excluded from BARI 2D and should undergo prompt revascularization. AbstractPatients with diabetes and coronary artery disease represent a challenging and growing subset of the population. Although surgical revascularization is the preferred treatment for patients with diabetes and multivessel coronary artery disease with stable angina, a significant proportion of diabetic patients undergo percutaneous revascularization due to comorbidities, presence of single-vessel disease, or presentation with myocardial infarction. The development of drug-eluting stents has significantly improved the results of percutaneous revascularization among diabetic patients, but a number of challenges remain, including higher rates of restenosis and stent thrombosis among diabetic patients. With current technologies, the outcomes of diabetic patients treated with noninsulin agents have approached that of nondiabetic patients. In comparison, patients with diab...

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Ticagrelor vs. clopidogrel in patients with acute coronary syndromes and diabetes: a substudy from the PLATelet inhibition and patient Outcomes (PLATO) trial

Cited by 389 publications

References 20 publications

Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus

Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus

Antiplatelet Therapy Changes for Patients With Myocardial Infarction With Recurrent Ischemic Events: Insights Into Contemporary Practice From the TRANSLATE‐ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) Study

Percutaneous Coronary Intervention in Patients With Diabetes

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