Myocardial Infarction - Myocardial Infarction - 307 · myocardial-infarction

Dr. Mia Ravn Jacobsen, M.D. - Clopidogrel, prasugrel, and ticagrelor for all-comers with ST-segment elevation myocardial infarction

Link to Abstract: https://www.internationaljournalofcardiology.com/article/S0167-5273(21)01192-X/fulltext#%20


Abstract\sBackground
To assess the efficacy and safety of clopidogrel, prasugrel, and ticagrelor in people who have had an ST-segment elevation myocardial infarction (STEMI) and to expand on what has been learned from randomized clinical studies.

Methods
The Eastern Danish Heart Registry was used to identify all consecutive STEMI patients admitted to Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Claim medicines and end points were gathered through individual linkage to Danish national registers. Patients alive a week after discharge were included in the study, and they were divided into three groups based on whether they were taking clopidogrel, prasugrel, or ticagrelor. They were then monitored for a year. Multivariate Cox proportional-hazards models were used to analyze the effectiveness end point (a composite of all-cause mortality, recurrent myocardial infarction, and ischemic stroke) and the safety end point (a composite of bleedings resulting to hospitalization).

Results
A total of 5123 patients (clopidogrel [1245], prasugrel [1902], ticagrelor [1976]) were enrolled in the study, with a 95 percent therapy persistency rate. Aspirin was taken at the same time in 95% of the cases. Females made up 24% of the population, while the elderly made up 17%. The efficacy endpoint occurred less frequently for ticagrelor (HR 0.50, 95 percent CI 0.35–0.70) and prasugrel (HR 0.48, 95 percent CI 0.33–0.68) as compared to clopidogrel, with no differences in bleedings requiring hospitalization. Prasugrel and ticagrelor have no differences in comparative effectiveness or safety. Similar results were found in sensitivity analyses using time-dependent drug exposure for the years 2011–2015.

Conclusions
When compared to clopidogrel, ticagrelor and prasugrel were linked with a lower incidence of all-cause mortality, recurrent myocardial infarction, and ischemic stroke in STEMI patients without an increase in bleeding that required hospitalization. There were no differences between prasugrel and ticagrelor.

Dr. Mia Ravn Jacobsen, M.D. - Clopidogrel, prasugrel, and ticagrelor for all-comers with ST-segment elevation myocardial infarction

Link to Abstract: https://www.internationaljournalofcardiology.com/article/S0167-5273(21)01192-X/fulltext#%20


Abstract\sBackground
To assess the efficacy and safety of clopidogrel, prasugrel, and ticagrelor in people who have had an ST-segment elevation myocardial infarction (STEMI) and to expand on what has been learned from randomized clinical studies.

Methods
The Eastern Danish Heart Registry was used to identify all consecutive STEMI patients admitted to Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Claim medicines and end points were gathered through individual linkage to Danish national registers. Patients alive a week after discharge were included in the study, and they were divided into three groups based on whether they were taking clopidogrel, prasugrel, or ticagrelor. They were then monitored for a year. Multivariate Cox proportional-hazards models were used to analyze the effectiveness end point (a composite of all-cause mortality, recurrent myocardial infarction, and ischemic stroke) and the safety end point (a composite of bleedings resulting to hospitalization).

Results
A total of 5123 patients (clopidogrel [1245], prasugrel [1902], ticagrelor [1976]) were enrolled in the study, with a 95 percent therapy persistency rate. Aspirin was taken at the same time in 95% of the cases. Females made up 24% of the population, while the elderly made up 17%. The efficacy endpoint occurred less frequently for ticagrelor (HR 0.50, 95 percent CI 0.35–0.70) and prasugrel (HR 0.48, 95 percent CI 0.33–0.68) as compared to clopidogrel, with no differences in bleedings requiring hospitalization. Prasugrel and ticagrelor have no differences in comparative effectiveness or safety. Similar results were found in sensitivity analyses using time-dependent drug exposure for the years 2011–2015.

Conclusions
When compared to clopidogrel, ticagrelor and prasugrel were linked with a lower incidence of all-cause mortality, recurrent myocardial infarction, and ischemic stroke in STEMI patients without an increase in bleeding that required hospitalization. There were no differences between prasugrel and ticagrelor.

Jeffrey J. Goldberger, MD, MBA from the University of Miami speaks about the Comparison of Metoprolol versus Carvedilol After Acute Myocardial Infarction.

Link to Article -
https://www.ajconline.org/article/S0002-9149(21)00155-7/fulltext#%20

• Beta-blockers are commonly administered after a heart attack, but no one brand has been recommended.

• In this analysis, metoprolol and carvedilol are compared in a post-MI cohort.

• Carvedilol and metoprolol had comparable overall survival rates in the sample.

• In the ejection fraction 40 percent subgroup, carvedilol outperformed metoprolol in terms of survival.

Summary

Following a myocardial infarction (MI), beta-blockers are commonly prescribed, although no particular beta-blocker is recommended. 4142 patients were discharged on metoprolol and 1487 on carvedilol from the OBTAIN multi-center list of patients with acute MI. The beta-blocker dose was calculated as a percentage of the target daily dose used in randomized clinical trials (metoprolol 200 mg; carvedilol 50 mg). >0 percent -12.5 percent (n=1428), >12.5 percent -25 percent (n=2113), >25 percent -50 percent (n=1392), and >50 percent (n=696) were the beta-blocker dose classes. Three-year survival was calculated using the Kaplan-Meier equation. A multivariable adjustment was used to correct for baseline variations. Carvedilol patients were older (64.4 vs. 63.3 years) and had more comorbidities, including hypertension, diabetes, previous MI, congestive heart failure, lower left ventricular ejection fraction, and a longer period of stay. The mean doses of metoprolol and carvedilol did not vary substantially (37.227.8% and 35.831.0%, respectively). The 3-year survival figures for metoprolol and carvedilol were 88.2% and 83.5 percent, respectively, with an unadjusted HR=0.72 (p0.0001), but HR=1.073 (p=0.43) after multivariable adjustment. In comparison to other dose ranges, patients in the >12.5-25 percent dose range had better survival. In a subgroup of patients with a left ventricular ejection fraction of less than 40%, metoprolol was found to have a worse survival rate than carvedilol (adjusted HR=1.281; 95 percent CI: 1.024-1.602, p=0.03). There were no variations in survival between carvedilol and metoprolol in patients with a left ventricular ejection fraction greater than 40%. Overall survival after acute MI was comparable in patients treated with metoprolol or carvedilol, but carvedilol could be superior in patients with a left ventricular ejection fraction of less than 40%.

Khaled Ziada, MD from the Cleveland Clinic discusses Cangrelor in ST-Elevation Myocardial Infarction to Decrease Infarct Size.


Link to the Clinical Trial-
https://clinicaltrials.gov/ct2/show/NCT03043274?cond=Heart+Attacks&cntry=US&phase=123&draw=2&rank=9

Summary Brief:
This research evaluates variations in the degree of myocardial necrosis observed by cardiac MRI in patients with randomized ST-elevated myocardial infarction who received cangrelor during the percutaneous coronary intervention and contrasts them with patients who did not receive cangrelor randomly.

Description in detail:
Cangrelor is a direct-acting and reversible intravenously administered platelet inhibitor approved as an alternative to percutaneous intervention (PCI) for reducing the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis. Cangrelor is emerging as an important new choice for use in patients undergoing percutaneous intervention who have not been treated with oral platelet inhibitors, as it has a fast onset of action (2 minutes) compared with conventional oral platelet inhibitors.



In addition, several studies have shown that patients undergoing emergent PCI with ST-elevation myocardial infarction (STEMI) do not have adequate platelet inhibition even after a loading dose of conventional oral platelet inhibitors has been given. The clinical meaning of maximum platelet inhibition at the time of PCI, however, is not fully understood.



The primary objective is to characterize the efficacy of intravenous cangrelor immediate platelet inhibition in patients with acute STEMI by determining the degree of infarct size (either enzymatically or by imaging). If the results are positive, this could indicate that in this patient population, immediate platelet inhibition is an important part of treatment.

Anders Holt, MD from Herlev and Gentofte University Hospital speaks about the Effect of long-term beta-blocker treatment following myocardial infarction among stable, optimally treated patients without heart failure in the reperfusion era: a Danish, nationwide cohort study.


Abstract:


Listen to this contribution's audio abstract at https://doi.org/10.1093/eurheartj/ehaa10588



Targets:


The goal was to research the long-term cardio-protective effect of beta-blocker (BB) therapy in healthy, optimally treated patients with myocardial infarction (MI) without heart failure (HF).



Methods and outcomes:

We included patients with first-time MI undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) during admission and treated between 2003 and 2018 with both acetyl-salicylic acid and post-discharge statins using national registries. Patients with a previous history of MI, prior use of BB, or any alternative indication or contraindication to treatment with BB have been removed. Follow-up started with patients alive, free of cardiovascular (CV) incidents or treatments, 3 months after discharge. CV death, repeated MI, and a composite outcome of CV events were the primary outcomes. 3 years after MI, we used modified logistic regression and reported standardized absolute hazards and differences (ARD). In total, 30,177 healthy, optimally treated MI patients were included (58 percent acute PCI, 26 percent sub-acute PCI, 16 percent CAG without intervention). 82% of patients were on BB therapy at baseline (median age 61 years, 75% male) and 18% were not (median age 62 years, 68% male). Compared to no BB treatment [ARD (95 percent confidence intervals)], BB treatment was associated with a comparable risk of CV death, recurring MI, and the cumulative outcome of CV events; 0.1 percent (−0.3 percent to 0.5 percent), 0.2 percent (−0.7 percent to 1.2 percent), and 1.2 percent (−0.2 percent to 2.7 percent).



Findings:

No long-term effect of BB treatment on CV prognosis was found in this nationwide cohort study of healthy, optimally treated MI patients without HF in patients aged 3 months to 3 years after MI admission.