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Editorial - February 2022



Dear Members,

Optimal platelet inhibition is one of the most important goals in the acute treatment of segment (ST)-elevation myocardial infarction (STEMI) patients. 1 Opioids are widely used in daily practice but delay the intestinal drug absorption of P2Y12 inhibitors.2 Moreover, nausea and vomiting are more frequently seen in patients receiving opioids,2,3 which further may reduce the uptake of oral platelet inhibitors. Therefore, treatment with dual antiplatelet therapy after an acute coronary event may often be tailor-made for the patient. In this newsletter the main findings and conclusions from newly published studies on this theme will be summarized:

Tavanier and co-workers concluded in a paper published in this issue of the EHJ-CVP that i.v. acetaminophen in comparison with i.v. fentanyl was not associated with significantly lower platelet reactivity in STEMI patients, but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief.

There are data suggesting that ticagrelor may possess antibacterial activity.4,5 In a Danish observational cohort study is i reported that treatment with ticagrelor was associated with a significantly lower 1-year risk of Staphylococcus aureus bacteremia, sepsis, and pneumonia compared with clopidogrel.

Dual antiplatelet therapy (DAPT) with a P2Y 12 inhibitor on top of aspirin is the cornerstone of therapy after acute coronary syndromes (ACSs). Nonetheless, the safest and most efficacious P2Y 12 for older patients who are at both high ischaemic and high bleeding risk remains uncertain.6 In a meta-analysis consisting of seven studies is concluded that among older subjects with ACS, DAPT should be balanced upon ischaemic and bleeding risks as prasugrel is associated with the highest probability of reduction of ischaemic events and clopidogrel with bleedings. Ticagrelor had highest surface under the cumulative ranking curve analysis for stent thrombosis reduction but seems suboptimal in older adults.

In a multicentre study led by Dr Valgimigli, the authors sought to assess whether the bleeding risk prediction offered by the PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti Platelet Therapy (PRECISE-DAPT)7–9 remains valid among patients receiving ticagrelor monotherapy from 1 month onwards after coronary stenting instead of standard DAPT and having or not having centrally adjudicated bleeding endpoints. They concluded that the PRECISE-DAPT offers a prediction model that proved similarly effective to predict clinically relevant bleeding among patients on ticagrelor monotherapy from 1 month after coronary stenting compared with standard DAPT and appears to be unaffected by the presence or absence of adjudicated bleeding endpoints.

Serruys and co-workers aimed to investigate the efficacy and safety of ticagrelor monotherapy in patients undergoing PCI stratified according to the baseline white blood cell (WBC) count. The authors reported that increased WBC counts, which may reflect degree of inflammation, at the time of index procedure, may attenuate the anti-ischaemic benefits of ticagrelor monotherapy observed in patients with lower WBC counts.

In a systematic review study from Korea, Hong et al. aimed to evaluate the effect of ticagrelor monotherapy after short-term DAPT after PCI on mortality. They concluded that ticagrelor monotherapy after short-term DAPT of 1 to 3 months was associated with decreased all-cause mortality and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding not offset by increase of cardiac death, ischaemic stroke, acute myocardial infarction, and stent thrombosis.

The optimal treatment period with DAPT is still to be determined.10–13 In a study from Italy, the authors report that the efficacy of short and very short is comparable with that of standard DAPT after DES implantation, whereas extended DAPT reduces the MI rate. Very short DAPT reduces haemorrhagic events and, followed by a P2Y 12 inhibitor monotherapy, may be preferred in order to pursue a trade-off between major bleeding and ischaemia. This paper is accompanied by an editorial by Dr Siontis from Switzerland.

There is a strong and ever-growing body of evidence regarding the use of pharmacogenomics to inform cardiovascular pharmacology. However, there is no common position taken by international cardiovascular societies to unite the diverse availability, interpretation, and application of such data, nor is there recognition of the challenges of variation in clinical practice between countries within Europe. We are very pleased to publish an ESC position paper from the Working Group of Cardiovascular Pharmacotherapy entitled ‘The Role of Pharmacogenomics in Contemporary Cardiovascular Therapy’. We also publish a current opinion from the same group. This viewpoint supplements the working group position paper on cardiovascular pharmacogenomics to address these important themes.

In relation to our educational courses, detailed information regarding programs are found on our webpage.

During 2022 we will also launch several educational and interactive webinars, on which further information will follow in coming newsletters and online.

We are launching a new educational programme: Cardiovascular Pharmacotherapy in women, which will be held online 17th-18th February 2022. The course will address unmet needs and knowledge gaps in the management of cardiovascular disease in women and aims at providing a balanced and practical view on the topic. Particular emphasis will be put on gender specific risk factors, dosing, evidence-based treatments and prevention of disease. The target audience will be health care personnel’s responsible for the care of women with CV conditions, as well as trainees aiming to enter these fields.

The Pharmacotherapy in Older People course was successfully held online the 14th-15th October 2021 and will also be held in 2022. Date to be decided. It is an engaging and interactive course to improve the professional knowledge and skills on cardiovascular pharmacotherapy in older patients. This is a great opportunity to improve the knowledge pharmacotherapy in older people for general physicians, care of the elderly professionals, nurses, cardiologists, nephrologists, diabetologists, trainees and healthcare professionals dealing with elderly patients in their daily clinical practice.

The All About Clinical Trials course was organised on 16-17 December 2021 and will also be held in 2022. This event will provide a deep insight into the long journey which brings pharmacological compounds from bench to bedside, i.e. from trial design for testing new drugs (generation of evidence and its critical appraisal) to implementation of pharmacological treatments for daily use in science and patient care. This course is essential for clinical cardiologists, clinical pharmacologists and healthcare professionals in general with an interest in translational and clinical research methodologies. Students and trainees will also have an opportunity to acquire or improve knowledge and clinical skills in clinical trial design, management and data interpretation.

EuroCVP was successfully held online 10-12 June 2021 and gave the best from our longstanding "All About Clinical Trials" course, to improve skills in designing and planning successful clinical trials. Moreover, profound discussions and expert panels enriched the record-breaking "Pharmacotherapy in Older People" course, to deliver better, personalized therapy for older patients. In addition to the highly successful course program, the designated highlight sessions provided an overview on pharmacotherapy and COVID-19, current challenges in pharmacogenomics, or on how to manage post-operative anti-thrombotic therapy after cardiovascular surgery.

The next edition of EuroCVP will be held on 30 June - 02 July in Florence, Italy! Save the date!

Cardiovascular Pharmacotherapists and Trialists of Tomorrow (CPTT) is the Young community of the ESC Working Group on Cardiovascular Pharmacotherapy, dedicated to young professionals under 40 years (physicians, nurses, scientists or others) with a special interest in cardiovascular pharmacotherapy and clinical trials. The benefits of joining the CPTT are many and we encourage you to join, it is free of charge. You need to be a member of the WG Cardiovascular Pharmacotherapy, which can be done on this webpage.

On behalf of the Working Group nucleus,
Alexander Niessner, Chairperson 2020-2022 and
Anne Grete Semb, Communication Coordinator 2020-2022

 

Retrieve other WG news

References

  1. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ, Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vrankcx P, Widimsky P, ESC Scientific Document Group. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119–177.
  2. Kubica J, Adamski P, Ostrowska M, Sikora J, Kubica JM, Sroka WD, Stankowska K, Buszko K, Navarese EP, Jilma B, Siller-Matula JM, Marszall MP, Rosc D, Kozinski M. Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. Eur Heart J 2016;37:245–252.
  3. Degrauwe S, Roffi M, Lauriers N, Muller O, Masci PG, Valgimigli M, Iglesias JF. Influence of intravenous fentanyl compared with morphine on ticagrelor absorption and platelet inhibition in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: rationale and design of the PERSEUS randomized trial. Eur Heart J Cardiovasc Pharmacother 2019;5:158–163.
  4. Storey RF, James SK, Siegbahn A, Varenhorst C, Held C, Ycas J, Husted SE, Cannon CP, Becker RC, Steg PG, Asenblad N, Wallentin L. Lower mortality following pulmonary adverse events and sepsis with ticagrelor compared to clopidogrel in the PLATO study. Platelets 2014;25:517–525.
  5. Li HL, Feng Q, Tsoi MF, Fei Y, Cheung BMY. Risk of infections in patients treated with ticagrelor vs. clopidogrel: a systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother 2021;7:171–179.
  6. Schäfer A, Flierl U, Bauersachs J. Anti-thrombotic strategies in elderly patients receiving platelet inhibitors. Eur Heart J Cardiovasc Pharmacother 2020;6:57–68.
  7. Gragnano F, Heg D, Franzone A, McFadden EP, Leonardi S, Piccolo R, Vranckx P, Branca M, Serruys PW, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, Diletti R, Dominici M, Huber K, Slagboom T, Buszman P, Bolognese L, Tumscitz C, Bryniarski K, Aminian A, Vrolix M, Petrov I, Garg S, Naber C, Prokopczuk J, Hamm C, Steg PG, Jüni P, Windecker S, Valgimigli M, GLASSY Investigators. PRECISE-DAPT score for bleeding risk prediction in patients on dual or single antiplatelet regimens: insights from the GLOBAL LEADERS and GLASSY. Eur Heart J Cardiovasc Pharmacother 2020; pvaa106. doi: 10.1093/ehjcvp/pvaa106.
  8. Kawashima H, Onuma Y, Serruys PW. Commentary regarding the article by Gragnano et al. PRECISE-DAPT score for bleeding risk prediction in patients on dual or single antiplatelet regimens: insights from the GLOBAL LEADERS and GLASSY. Eur Heart J Cardiovasc Pharmacother 2021;7:e64.
  9. Costa F, Valgimigli M, Steg PG, Bhatt DL, Hohnloser SH, Ten Berg JM, Miede C, Nordaby M, Lip GYH, Oldgren J, Cannon CP. Antithrombotic therapy according to baseline bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention: applying the PRECISE-DAPT score in RE-DUAL PCI. Eur Heart J Cardiovasc Pharmacother 2020;pvaa135. http://dx.doi.org/10.1093/ehjcvp/pvaa135.
  10. Goto S, Goto S. Is the answer to clinical questions provided by Bayesian network meta-analysis? Regarding the optimal duration of DAPT and the best subsequent SAPT. Eur Heart J Cardiovasc Pharmacother 2021;7:216–217.
  11. Bianco M, Careggio A, Destefanis P, Luciano A, Perrelli MG, Quadri G, Rossini R, Campo G, Vizzari G, D'Ascenzo F, Anselmino M, Biondi-Zoccai G, Ibáñez B, Montagna L, Varbella F, Cerrato E. P2Y12 inhibitors monotherapy after short course of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a meta-analysis of randomized clinical trials including 29 089 patients. Eur Heart J Cardiovasc Pharmacother 2021;7:196–205.
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